Soemmering's Ring Research Articles

Simple ab externo lens capsule removal in intraocular lens reuse and intrascleral fixation for intracapsular lens dislocation: A case report.

This study aimed to report and recall a simple method to remove the lens capsule ab externo when performing intrascleral fixation of an intracapsular intraocular lens (IOL) dislocation with reuse of the IOL. A 43-year-old Japanese male patient underwent pars plana vitrectomy, phacoemulsification, and IOL fixation for rhegmatogenous retinal detachment in the right eye 10 years prior. A 3-piece IOL was intraocularly fixed during the initial procedure. In December 2023, the patient presented with intracapsular IOL dislocation in his right eye, causing the IOL to descend into the vitreous cavity enveloped by its entire capsule. During surgery, an intravitreal dislocated IOL was placed over the iris with the entire capsule. The haptics on 1 side of the IOL were placed outside the eye through the corneoscleral wound. Subsequently, the lens capsule and Soemmerring's ring surrounding the haptics were removed. After the haptics were placed back over the iris, the same extraction procedure was performed for the remaining haptics. The IOL was intrasclerally fixed using a flange technique through the intrascleral tunnel at the 4 and 10 o'clock positions. One week postsurgery, the best-corrected visual acuity of the right eye was 20/16, and the corneal endothelial cell density was recorded as 2923 cells/mm2 (preoperative: 1650 cells/mm2). In cases of 3-piece IOL dislocation, employing the ab externo technique for lens capsule extraction has been proven to be a straightforward and efficient method. This approach facilitates the removal of the lens capsule around the IOL. If subsequent damage to the IOL is identified, it allows for easy conversion to replacement.

Unintended placement of intraocular lens haptics in the sulcus and its association with posterior capsular opacification in pseudophakic post-mortem eyes

ObjectiveTo assess the prevalence of unintended placement of intraocular lens (IOL) haptics in the sulcus and its association with posterior capsular opacification (PCO). DesignCross-sectional study. Participants428 post-mortem pseudophakic human eyes. MethodsEyes were obtained from the Lions Gift of Sight and imaged in Miyake-Apple view (MAV). IOL haptic placement (bag–bag, bag–sulcus, sulcus–sulcus) was determined from the MAV images. IOL-capsular bag complexes were extracted and analyzed via Automated Detector Opacification Software to quantify PCO and Soemmering's Ring (SR). SR distribution was categorized as focal, diffuse, or none. Mean differences in PCO and SR between haptic groups were assessed via Welch's t-test. Odds ratios were used to compare the risk of SR distribution patterns between both haptic groups. Sex, clinical history (diabetes, smoking, hypertension, glaucoma, cancer, age-related macular degeneration [AMD], hypercholesterolemia, cardiovascular disease), and IOL model and specifications were collected. Results20 eyes (4.67%) had unintended sulcus placement of haptics. Mean PCO (p = 0.0367) and SR (p = 0.0414) were significantly higher in sulcus eyes. Sulcus eyes were significantly more at risk of focal SR distribution (OR 8.715; p < 0.0001) and significantly less at risk of diffuse SR distribution (OR 0.168; p = .0007). Sulcus eyes had significantly higher frequencies of glaucoma (p < 0.0001) and AMD (p = 0.0023) on clinical history. ConclusionsThis study demonstrates that unintended sulcus placement of IOL haptics may be associated with an increased risk of PCO and SR formation. This study offers clinical signs of sulcus haptic placement that may prompt physicians to seek earlier appropriate intervention.

Objective analysis of capsulorrhexis factors and posterior capsular opacification in 420 postmortem eyes

ObjectiveTo evaluate the capsulorrhexis structure in postmortem eyes and determine factors associated with posterior capsular opacification (PCO). DesignExperimental study. ParticipantsPostmortem pseudophakic human eyes (n = 420). MethodsPostmortem eyes were obtained and examined. Photographs were taken of the eyes in Miyake-Apple view and of the extracted lens-capsule complexes. PCO and Soemmering's ring (SR) were quantified using automated detector opacification software as factors of intensity and area. Miyake-Apple views and ImageJ were used to assess capsulorrhexis diameter, area of anterior capsule-optic overlap, length of the shortest anterior capsular leaflet, and area and angle of capsulorrhexis-optic nonoverlap. Linear regression analysis and Welch's t test were used to determine the relationship of these factors with PCO and SR. All analyses were repeated in sample groups specific to the 5 most common intraocular lens models. ResultsCapsule-optic overlap was positively correlated with PCO (P < 0.0001) and SR (P = 0.0016). Capsulorrhexis diameter was negatively correlated with PCO (P < 0.0001) and SR (P = 0.014). Leaflet length was positively correlated with PCO (P = 0.009). Area and angle of capsulorrhexis-optic nonoverlap were not correlated with PCO or SR. Slopes and coefficients of determination were relatively low for all significant results. ConclusionsThe pathogenesis of PCO development after cataract surgery is multifactorial. This study shows that with modern operating technology, capsulorrhexis factors have at best a modest influence on PCO formation. Factors such as time from surgery to death and intraoperative techniques such as laser capsule polishing, posterior capsule vacuuming, and cortical cleanup are likely to play a more significant role.

Technique: Removal of Soemmering's Ring Using an Intraocular Lens Cartridge

Technique: Removal of Soemmering's Ring Using an Intraocular Lens Cartridge

Soemmerring's rings developed in‐vivo can present internal transparent areas

Purpose: To test whether any part of Soemmerring's rings developed, in‐vivo, in adults could be transparent and how this transparency relates to morphological factors.Methods: Sixteen Soemmerring's rings were extracted from donor eye globes. After frontal imaging, they were thickly sectioned sagittally in order to analyse the degrees of transparency of the cross‐section both at the periphery and center. All samples were also histologically analysed using alpha smooth muscle actin, Vimentin, wheat germ agglutinin and DAPI in order to correlate transparency to certain morphological factors.Results: When viewed frontally within the dark field, all Soemmerring's ring samples were apparently opaque. However, after sectioning, 20 of the 30 samples were more transparent in the center than at the periphery. Of the morphological factors that we analysed, only lens fibre organization at the bow region and an increased area of mature lens fibre cells had a significant relation to the degree of transparency at the center of cross‐sections.Conclusions: Soemmerring's rings can maintain the ability to produce organized and transparent areas of lens cells.

Dislocated Soemmering's Ring in the Anterior Chamber

Dislocated Soemmering's Ring in the Anterior Chamber

Clinical and anatomic correlates of objectively measured zonular dehiscence in 427 postmortem pseudophakic eyes

ObjectifLa présente étude vise à mesurer de manière objective le degré de déhiscence zonulaire dans des yeux de donneurs cadavériques et à évaluer les corrélations cliniques et anatomiques. NatureÉtude transversale. MatérielQuatre cent vingt-sept yeux pseudophaques de donneurs cadavériques humains. MéthodesLes yeux provenaient de la banque d'yeux Lions Gift of Sight. Les photographies des yeux au microscope consistaient en une vue postérieure de segment antérieur (Miyake–Apple view); on a eu recours au logiciel ImageJ pour réaliser l'analyse de la zone visée afin de mesurer l'aire, la circonférence et le diamètre du sac capsulaire, de l'anneau ciliaire et du capsulorhexis. Les paramètres cliniques et anatomiques ont été évalués grâce à une analyse de régression linéaire simple et à une analyse de la variance à un facteur s'accompagnant d'un test de Bonferroni. On s'est servi de 2 paramètres de substitution pour mesurer la déhiscence zonulaire : le rapport de l'aire de la capsule sur l'aire de l'anneau ciliaire (CCR, pour capsule area over ciliary ring area ratio) et la décentration de la capsule par rapport à l'anneau ciliaire (CCD, pour capsule-ciliary ring decentration). Un CCR faible et une CCD élevée correspondent à une déhiscence zonulaire plus prononcée. RésultatsOn a noté une corrélation inverse significative entre le CCR et un capsulorhexis de plus petite taille (p = 0,012), une lentille intraoculaire de plus faible puissance (p < 0,00001), un âge moins avancé lors du décès (p = 0,00002) et un délai plus long entre l'apparition des cataractes et le décès (p = 0,00786). Le CCR était en outre significativement plus faible en présence de glaucome (p = 0,0291). Par ailleurs, la CCD était en corrélation significative avec un délai plus long entre l'apparition des cataractes et le décès (p = 0,000864), une plus grande aire de l'anneau ciliaire (p = 0,001), une opacification plus prononcée de la capsule postérieure (p = 0,0234) et une opacité plus prononcée de l'anneau de Soemmering (p = 0,0003). Enfin, on a enregistré significativement plus de décentration dans les yeux d'hommes que dans les yeux de femmes (p = 0,00852). ConclusionsLe CCR et la CCD constituent de nouvelles façons de mesurer la déhiscence zonulaire dans des yeux de donneurs cadavériques et permettent de mettre au jour de nombreuses corrélations intéressantes. Un élargissement de l'aire de l'anneau ciliaire pourrait être associé à une déhiscence zonulaire dans des yeux pseudophaques et peut vraisemblablement servir de variable de substitution quantifiable in vivo.

Soemmerring's Rings Developed around IOLs, in Human Donor Eyes, Can Present Internal Transparent Areas.

Soemmerring's rings consist of a ring of lens epithelial derived cells that grow along the periphery of an aphakic lens capsule, or around an intraocular lens. These rings when visualized frontally, appear opaque, however, in some cases the cells that compose these rings are organized in the same fashion as those in normal transparent adult lenses. Thus, our purpose was to test whether any part of the adult Soemmerring's ring could be transparent and how this related to morphological factors. To study this, 16 Soemmerring's rings were extracted from donor eye globes. After imaging, they were thickly sectioned sagittally in order to analyze the degrees of transparency of different areas. All samples were also histologically analyzed using alpha smooth muscle actin, Vimentin, wheat germ agglutinin and DAPI. Our results showed that many samples had some transparent areas, mostly towards the center of their cross-section. Of the factors that we analyzed, only lens fiber organization at the bow region and an increased area of mature lens fiber cells had a significant relation to the degree of transparency at the center. Thus, we can conclude that as Soemmerring's rings mature, they can develop organized and transparent areas of lens cells.

Endoscopic Visualization for Atypical Uveitis Glaucoma Hyphema Syndrome Management.

We discuss how ophthalmic endoscopy was used in the management of 6 cases with atypical uveitis glaucoma hyphema syndrome. For case 1, the endoscope was used to remove a retained haptic foreign body after an intraocular lens (IOL) exchange with an iris-sutured IOL for a complete capsular bag-IOL complex dislocation. In case 2, the endoscope was key in identifying the presence and location of vascular lesions at the site of previous pars plana sclerotomies. In case 3, the endoscope enabled visualization of a large segmental Soemmering's Ring pushing a 3-piece IOL haptic into the posterior iris. For case 4, the endoscope allowed viewing of the sharp edge of the optic where the haptic of a one-piece lens had been amputated, and the sharp edge of the cut optic was anteriorly oriented and continuing to rub the posterior iris. In case 5, the endoscope confirmed the presence of 1 haptic of a 1-piece lens out of the capsular bag and in the sulcus space. Also, it showed that the capsular bag had inadequate zonular support to attempt repositioning the haptic into the bag. In case 6, the endoscope was helpful in identifying a 1-piece plate haptic IOL in the sulcus, with synechiae and anterior location causing iris bulging inferiorly.

Uveitis-glaucoma-hyphema syndrome secondary to an in-the-bag intraocular lens with capsular fibrosis

A patient developed pseudoexfoliative glaucoma and hyphema syndrome with an appropriately placed, in-the-bag single-piece lens. Ultrasound biomicroscopy showed a Soemmering ring, extensive fibrotic bands tethering the capsule to the ciliary body, and localized ciliary body traction. An anterior chamber washout, peeling of the fibrotic bands, and capsular phimosis correction were performed. Uveitis-glaucoma-hyphema syndrome may be caused by a nontilted in-the-bag lens, precipitated by the formation of tractional fibrotic bands, a Soemmering ring, and a predisposition to zonular laxity from pseudoexfoliative syndrome. Surgical peeling of the capsular fibrosis may be the most important factor in preventing recurrent hyphema.

Mélanose conjonctivale ethnique bilatérale et cataracte congénitale

We report the case of a female child aged eight years presenting with total congenital cataract in the right eye. The patient had a history of left eye cataract surgery with implantation into the capsular bag. Examination found maximum bilateral conjunctival pigmentation at the level of the limbus, invading the bulbar conjunctiva. Examination of the left eye showed Soemmering ring. The main differential diagnoses included congenital melanosis and acquired melanosis. No specific management was undertaken for conjunctival melanosis and simple monitoring was recommended. Ethnic or racial melanosis is common in patients with brown pigmentation and is characterized by a proliferation of benign melanocytes along the basal membrane of the epithelium. The risk of malignant transformation is very rare, therefore regular monitoring is recommended.

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

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

Capsular Bag Distention Syndrome after 9 years of Cataract Surgery

A 65-year-old male presented with complaints of foggy vision and glare in the right eye since 2 months. He had an uneventful cataract surgery in the right eye 9 years back and in the left eye 4 years back following which he had gained a visual acuity of 6/9 in both eyes. On examination his distance visual acuity was 6/12 in the right eye. Slit-lamp examination shows a peripheral soemmering ring and on careful inspection of the right eye posterior-chamber intraocular lens (PCIOL), a yellow-whitish turbid fluid collection was observed (Figure A).

Dislocated Soemmering Ring in a Myopic Eye

Dislocated Soemmering Ring in a Myopic Eye

Time Course of Lens Epithelial Cell Behavior in Rabbit Eyes following Lens Extraction and Implantation of Intraocular Lens.

Background After cataract surgery, some lens epithelial cells (LECs) transdifferentiate into myofibroblast-like cells, which causes fibric posterior capsule opacification (PCO). Residual LECs differentiate into lens fiber cells, forming Elschnig pearls with PCO. This study was carried out to identify the time course of both types of LEC behavior in rabbit eyes following lens extraction and implantation of an intraocular lens (IOL). Methods Phacoemulsification and implantation of posterior chamber IOLs were performed in rabbit eyes. Following enucleation, immunohistochemical methods were used to detect α-smooth muscle actin (α-SMA), a marker for myofibroblast-like cells, in the pseudophakic rabbit eyes. A mouse monoclonal antibody against α-SMA was used. Results Soon after the operation, the LECs migrated and covered the lens capsule. Thereafter, the LECs around the anterior capsular margin were always positive for α-SMA. However, the distributions of these cells were not consistent. In some specimens, α-SMA-positive LECs were present around the IOL optic early after surgery, but most of them had disappeared several weeks after the surgery. The residual cells induced fibrotic PCO. In the other specimens, most LECs around the IOL optic except the anterior capsular margin were negative for α-SMA. In the peripheral region covered by the peripheral anterior and posterior capsules, LECs on the posterior capsule always differentiated into lens fiber cells and formed a Soemmering ring. Thereafter, migration of lens fiber cells from the Soemmering ring and differentiation of LECs in situ on the central posterior capsule consisted of Elschnig pearls type of PCO. Conclusions Although postoperative LEC behavior is not consistent, residual α-SMA-positive LECs induced fibrotic PCO. The lens fiber cells that migrated from the peripheral capsular bag or that were differentiated in situ covered the central posterior capsule, forming Elschnig pearls with PCO.

Application of an iris speculum for removing Soemmerring's ring during secondary intraocular lens implantation in congenital cataract patients with small pupils.

An application of the XpandNT iris speculum in eyes with small pupils during secondary intraocular lens (IOL) implantation in congenital cataract patients is described. The iris speculum was first positioned in the eye to expand the pupil. A 30-gauge needle was used to separate the adhesion of the iris tissue and the capsular rim. Vitrectomy was used to clean Soemmerring's ring near the capsular rim. The iris expander was retracted with the Williamson XpandNT Manipulator. The IOL was then implanted. Fourteen aphakic eyes from 10 consecutive patients were studied retrospectively; pupil expansion was achieved in all 14 eyes intraoperatively without serious intraoperative or postoperative complications. The iris speculum was a safe and excellent tool for removing Soemmerring's ring and solving small pupil problems during secondary IOL implantation in pediatric cataract surgery patients.

Posterior capsule opacification: What's in the bag?

Cataract, a clouding of the lens, is the most common cause of blindness in the world. It has a marked impact on the wellbeing and productivity of individuals and has a major economic impact on healthcare providers. The only means of treating cataract is by surgical intervention. A modern cataract operation generates a capsular bag, which comprises a proportion of the anterior capsule and the entire posterior capsule. The bag remains in situ, partitions the aqueous and vitreous humours, and in the majority of cases, houses an intraocular lens (IOL). The production of a capsular bag following surgery permits a free passage of light along the visual axis through the transparent intraocular lens and thin acellular posterior capsule. Lens epithelial cells, however, remain attached to the anterior capsule, and in response to surgical trauma initiate a wound-healing response that ultimately leads to light scatter and a reduction in visual quality known as posterior capsule opacification (PCO). There are two commonly-described forms of PCO: fibrotic and regenerative. Fibrotic PCO follows classically defined fibrotic processes, namely hyperproliferation, matrix contraction, matrix deposition and epithelial cell trans-differentiation to a myofibroblast phenotype. Regenerative PCO is defined by lens fibre cell differentiation events that give rise to Soemmerring's ring and Elschnig's pearls and becomes evident at a later stage than the fibrotic form. Both fibrotic and regenerative forms of PCO contribute to a reduction in visual quality in patients. This review will highlight the wealth of tools available for PCO research, provide insight into our current knowledge of PCO and discuss putative management of PCO from IOL design to pharmacological interventions.

Assessment of Post-Operative Pseudophakic Glaucoma by Ultrasound Biomicroscopy.

PurposePseudophakic glaucoma is a secondary glaucoma in which intra-ocular pressure is elevated following cataract removal. The current study aimed to evaluate the role of ultrasound biomicroscopy (UBM) in assessing post-operative pseudophakic glaucoma.Patients and MethodsThis is a case series, prospective, observational and analytical study. It included 29 eyes of 29 patients with post-operative pseudophakic glaucoma. The patients were evaluated by medical history, detailed ophthalmologic examination and UBM.ResultsUBM examination has unmasked different causes of pseudophakic glaucoma. The detected causes were classified into 3 main groups, including intraocular lens (IOL)-related causes, lens remnants and intra-ocular inflammation. Haptic-related causes were present in 9 eyes, while 6 eyes had decentered or tilted IOLs. Soemmering’s ring was the main cause in 3 eyes while in one eye the cause was lens particle in the anterior chamber (AC). Silicone oil in AC with seclusio pupillae was the main cause in one eye. Peripheral anterior synechiae were detected in 8 eyes while, posterior synechiae were evident in 7 eyes. Uveitis induced by anterior chamber IOL (ACIOL) was found in 3 eyes and one eye had peripheral anterior synechiae due to neovascular glaucoma.ConclusionUBM is a helpful diagnostic tool to evaluate causes of pseudophakic glaucoma through adequate visualization of different angle structures.

Further Enhancement of Intraocular Open-Capsule Devices for Prevention of Posterior Capsule Opacification.

PurposeWe improve the intraocular open-capsule devices (IOCD) for the prevention of posterior capsule opacification (PCO).MethodsA total of 45 New Zealand rabbit eyes were divided into six similar groups after crystalline lens evacuation. Each group was implanted with a hydrophilic intraocular lens (IOL) and a hydrophilic IOCD of different designs. In the first experiment (Part A), a square design ring with and without large apertures was compared to a round design ring without apertures. In the second experiment (Part B), a square design ring with large apertures was compared to square design IOCDs with small apertures of high and low density. PCO and Soemmering's ring were evaluated clinically, by the Miyake Apple view, and histologically. The results were compared to a control group of eyes implanted with a hydrophilic IOL only.ResultsAll devices showed significant prevention of PCO and Soemmering's ring compared to the control group. Part A: the square design with apertures had the lowest level of peripheral lens epithelial cells proliferation (protrusions). Part B: modifying the size and density of the apertures had no influence on those protrusions.ConclusionsThe IOCD significantly reduced the rate of PCO and its precursor, Soemmering's ring. The rings with the square edges and apertures produced the best results. The study was underpowered to determine the influence of the apertures design.Translational RelevanceThe IOCD has the potential to prevent up to 80% of the PCO cases; the most common complication after cataract surgery. The design of the ring is important for its success.

Long-term uveal and capsular biocompatibility of a novel modular intraocular lens system.

We evaluated the long-term biocompatibility and safety of a new modular posterior chamber intraocular lens (IOL) system in rabbit eyes. Seven New Zealand rabbits underwent bilateral phacoemulsification with placement of the modular IOL in OD and a control IOL (SA60AT) in OS. Slit-lamp examinations were performed at postoperative weeks 1, 2, 3, 4, 6 and 8 and months 3 and 6. All rabbits were then sacrificed and eyes enucleated. The eyes were examined grossly from the Miyake-Apple view. Selected IOLs were explanted and underwent surface staining for implant cytology. All globes were then sectioned and processed for histopathological examination. The modular IOL remained stable in all seven rabbits through the entire follow-up period. Biocompatibility was better than the control lens at six months postoperatively, on account of less extensive synechiae formation as assessed by slit-lamp examination. At the six-week examination, posterior capsule opacification (PCO) was significantly better in the test group (scored as 1.71±0.8 versus 3.28±0.48 in the control group, p=0.0008). On gross examination with the Miyake-Apple view, Soemmering's ring formation was significantly better in the test group, (5.14±1.57 versus 10.85±1.95 in the control group, p=0.002). Previous studies showed that explantation/exchange of the modular system optic was safer and easier than with a standard IOL. The new modular IOL system has demonstrated better long-term biocompatibility compared to the control lens at six months postoperatively in the rabbit model.