Uncomplicated Extracapsular Cataract Extraction Research Articles

Uncommon complication following uneventful Nd:YAG capsulotomy

This article reports the development of low grade endophthalmitis following Nd:YAG laser posterior capsulotomy. The patient previously underwent uncomplicated extracapsular cataract extraction with intraocular lens (IOL) insertion and was free of inflammation prior to laser capsulotomy. Anterior vitrectomy with partial capsular bag removal and anterior chamber washout were performed. Samples for cultures were taken and intravitreal antibiotics injected. The patient was managed with topical and systemic antibiotics and steroids. Complete resolution of the inflammation with return of vision to 20/25 was achieved without removal of the intraocular lens or lenticular remnants. The endophthalmitis was responsive to a minimally invasive intervention as well as medicinal therapy including antibiotic agents, and it resolved without any invasive surgical intervention, such as total capsulectomy, IOL exchange or removal and posterior vitrectomy.

Impaired Corneal Wound Healing Associated With Ketorolac 0.5% After Uncomplicated Extracapsular Cataract Extraction

To describe an apparent association between the use of ketorolac 0.5% (Acular; Allergan) for cystoid macular edema (CME) prophylaxis and impaired corneal wound healing in patients undergoing extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation. A retrospective case series reviewing 7 eyes of 7 patients who underwent uncomplicated ECCE with IOL implantation and were treated postoperatively with ketorolac 0.5% 4 times daily as a prophylactic measure against CME. Patients were treated with ketorolac 0.5% 4 times a day for an average of 30 days (range, 20-44 days) after uncomplicated ECCE with IOL implantation. Two eyes developed postoperative endophthalmitis necessitating vitreous tap with intravitreal antibiotic injection; 1 eye went on to require pars plana vitrectomy with corneal wound resuturing. One eye developed corneal wound dehiscence that required wound resuturing in the operating room. One eye developed an inadvertent filtering bleb despite the lack of postoperative suture lysis. Three others were followed up closely postoperatively with slit-lamp evidence of impaired wound healing, manifested by wound avascularity and/or wound gape, and did not require surgical intervention. The use of nonsteroidal anti-inflammatory agents for prophylaxis of CME after cataract surgery is an evolving trend. This retrospective case series showed a possible link between the use of ketorolac 0.5% and impaired corneal wound healing, and caution is urged in the liberal use of this agent postoperatively after ECCE.

Keratectasia as a Presentation of Surgically Induced Necrotizing Sclerokeratitis (SINS)

A case of keratectasia is reported as a severe presentation of surgically induced necrotizing sclerokeratitis (SINS). A 72-year-old white woman had a painful, raised lesion on the superior cornea of her right eye 3 years after uncomplicated extracapsular cataract extraction with intraocular lens implantation. Examination showed a large ectatic area of the superior cornea with inflamed sclera adjacent to the surgical wound, which was diagnosed as SINS. No underlying systemic autoimmune condition or vasculitis was identified on investigation. Progressive painful keratectasia necessitated enucleation, which confirmed on histopathologic examination features of chronic nodular episcleritis and nongranulomatous scleritis with evidence of keratitis and fibrovascular scarring. The predominant inflammatory response in the cornea represents surgically induced necrotizing keratoscleritis (SINK) as a new variant presentation of SINS. Oral corticosteroids and immunosuppressive agents should not be delayed to prevent progressive tissue destruction and poor outcome.

Chronic postoperative endophthalmitis due to pseudomonas oryzihabitans

PURPOSE: To report a case of chronic postoperative endophthalmitis caused by the gram-negative bacterium Pseudomonas oryzihabitans. DESIGN: Interventional case report. METHODS: A 77-year-old man was referred to our service for nonpainful uveitis in the right eye accompanied by increased intraocular pressure of 2 years’ duration with onset 4 months after uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation. The uveitis partially responded to topical corticosteroid therapy but was recurrent with tapering of steroids. An anterior chamber tap and vitreous biopsies sent for cultures were negative. Owing to the persistence of inflammation despite intraocular vancomycin injection, the lens implant and capsule were removed and culture of the latter revealed the bacterium P. oryzihabitans. RESULTS: There was no recurrence of inflammation after removal of the lens implant and capsule. CONCLUSIONS: Unlike other gram-negative organisms, which are associated with poor outcomes, P. oryzihabitans may masquerade as chronic uveitis because of its low virulence.

Functional and anatomic outcome of retinal detachment surgery in pseudophakic eyes

PurposeTo determine the long-term anatomic and functional visual outcome of retinal detachment (RD) surgery in pseudophakic eyes after uncomplicated cataract surgery. DesignAn interventional, retrospective noncomparative case series ParticipantsOne hundred thirty-eight consecutive patients who had undergone uncomplicated extracapsular cataract extraction and intraocular lens implantation followed by rhegmatogenous RD between 1990 and 1995. MethodsOne hundred one eligible patients were examined (inclusion ratio, 73%) a median of 4.3 years after last RD surgery. The best-corrected visual acuity (BCVA), visual fields, retinal status, and patient-rated visual outcome were recorded, the latter by a questionnaire that included self-reported satisfaction, trouble with vision, a modified Cataract Symptom Score, and the VF-14 Visual Functioning Index. Main outcome measuresBCVA, retinal attachment, diameter of visual field, modified Cataract Symptom Score, VF-14 score. ResultsBaseline characteristics of enrolled and nonenrolled patients were comparable, except that nonenrolled patients were older. When RD developed, 55 eyes had an intact posterior capsule, and 46 had a laser posterior capsulotomy (LCT). The BCVAs before (median, logarithm of the minimum angle of resolution [−logMAR] 1.2 versus 1.1, Snellen equivalent 0.063 versus 0.08) and after retinal surgery (median, −logMAR 0.46 versus 0.4, Snellen equivalent 0.35 versus 0.4) were comparable for eyes with and without LCT (P = 0.86). The retina was reattached with one procedure in 75 eyes (74%), with two procedures in 98 eyes (97%), and with three to five procedures in all eyes. The retina remained attached long term in 92 eyes (91%). Redetachment rate (9% versus 9%, P = 1.0) and visual field diameters were comparable for eyes with and without LCT. Overall, 80% of patients were satisfied or very satisfied with their binocular vision, and 62% had no or only a little trouble with binocular vision. Visual performance was similar regardless of presence or absence of LCT (median Cataract Symptom Score, 3.0 versus 3.0, P = 0.76; and median VF-14 score, 87.5 versus 87.5, P = 0.81). ConclusionsNine in 10 pseudophakic retinal detachments remain attached long term, and 8 in 10 patients are satisfied with their binocular vision after surgery. Even though secondary cataract and posterior capsulotomy can cause problems for the retinal surgeon, the anatomic and functional outcomes of pseudophakic RD are not influenced by capsulotomy.

12 year results of a prospective trial comparing poly(methyl methacrylate) and poly(hydroxyethyl methacrylate) intraocular lenses

Purpose To compare long-term biocompatibility of single-piece poly(methyl methacrylate) (PMMA) and poly(hydroxyethyl methacrylate) (P-HEMA) intraocular lenses (IOLs). Setting District General Hospital, United Kingdom. Methods In a prospective trial of 250 eyes that had uncomplicated extracapsular cataract extraction, 2 groups of 125 eyes each were matched for age and sex. One group received single-piece looped PMMA IOLs and the other, single-piece solid-hapticP-HEMA IOLs. In all eyes, the IOLs were implanted in the capsular bag at the time of surgery using the envelope technique. Results Twelve years after surgery, 75 eyes were available for examination. In the PMMA group (40 eyes), 50% had a visual acuity of 20/20 and 50% had intact capsules, many of them with a degree of fibrosis. In the P-HEMA group (35 eyes), 71% had an acuity of 20/20 and 80% had intact capsules ( P = .0085). Conclusion In the long term, biocompatibility was better in the P-HEMA group than in the PMMA group.

Retinal detachment in pseudophakic eyes with and without Nd:YAG laser posterior capsulotomy

Objective This study aimed to determine whether the characteristics of pseudophakic retinal detachment (RD) differ in eyes with and without a neodymium (Nd):YAG laser capsulotomy to identify features that might help to treat capsulotomy patients better. Design The study design was a retrospective cohort study of 129 consecutive eyes, 61 with a capsulotomy and 68 control eyes with an intact posterior capsule, in which a primary rhegmatogenous RD developed after a strictly uncomplicated extracapsular cataract extraction and intraocular lens implantation. Setting The study was conducted in a primary referral center. Main outcome measures Number, type, and location of retinal breaks and type and extent of RD were measured. Results Risk factors predisposing to RD did not differ between the capsulotomy and control group. The median interval from cataract surgery to RD was expectedly longer in the capsulotomy group (4.1 years vs. 1.5 years, P < 0.001). The mean number of retinal breaks was larger in the capsulotomy group (1.7 vs. 1.1, P = 0.05), especially in upper quadrants (82 of 103 vs. 48 of 77, P = 0.024). Capsulotomy eyes also had a trend to have more atrophic holes that caused detachment relative to horseshoe breaks (34 of 103 vs. 15 of 77, P = 0.062). The type and extent of RD were similar in the two groups. Conclusions This pilot study suggests that atrophic holes, particularly in the superior quadrants, may lead to RD preferentially after posterior capsulotomy. Early identification and treatment of such breaks might decrease the number of pseudophakic detachments after capsulotomy.

Do Mersilene sutures need to be removed after cataract surgery?

A major disadvantage of nylon sutures is the need to remove them post-operatively to prevent suture fracture and irritation. Mersilene (polyester) sutures do not hydrolyse or disintegrate and are in theory superior to nylon. Fifty-two consecutive patients were examined an average of 3 years after uncomplicated extracapsular cataract extraction with corneal sections sutured with interrupted 11/0 polyester. It was found that 29% had suture-related problems and required, or had previously undergone, suture removal for reasons other than high astigmatism. The most common problem was a loose stitch with adherent mucus and corneal vascularisation (17% of patients at review). Sixty-six per cent of patients with loose sutures reported discomfort. We would not advocate prophylactic removal, but patients with polyester sutures should be advised to return if they become symptomatic.

Post-operative astigmatism control by selective suture removal

Fifty eyes in 50 patients with > 2.5 dioptres (D) of with-the-rule astigmatism (refraction) following uncomplicated extracapsular cataract extraction were recruited for this prospective study. Selected single sutures were removed and both the amount of astigmatic loss and the change in axis were measured at intervals. After removal of the first suture the mean astigmatic loss at 1 week was 2.9 D by keratometry and the mean change in the axis was 23 degrees (74% occurred within the first hour). The astigmatic loss was greater with subsequent suture removal. Timing of suture removal (before or after 8 weeks) and the amount of initial post-operative astigmatism (more than or less than 5 D) had a minimal effect on the total astigmatic loss. We suggest selective single suture removal can be performed safely at 5-6 weeks post-operatively with removal of a second suture, if necessary, in the steepest axis after 1 hour. The prescription of spectacles should be delayed for 1 week after the final suture has been removed.

Laser flare-cell measurement of inflammation after uneventful extracapsular cataract extraction and intraocular lens implantation

Purpose: To prospectively evaluate the inflammation response after uneventful extracapsular cataract extraction (ECCE) and intraocular lens (IOL) implantation.Setting: Department of Ophthalmology, University of Alicante, Spain.Methods: Using a Kowa laser flare-cell meter, we measured cell and flare for 3 months postoperatively in 550 eyes of 435 consecutive patients who had uneventful ECCE and IOL implantation. We compared the results in terms of the type of IOL implanted.Results: The amount of inflammation varied, but not significantly, according to the IOL type. The highest level of flare and cell always occurred the day following surgery regardless of which IOL was used. A small increase in flare was observed on the 30th day.Conclusion: Inflammation after uncomplicated ECCE, as measured with a laser flare-cell meter, resolved by 3 months and was not significantly affected by the type of IOL implanted. More sensitive instruments should be developed to measure inflammation immediately after surgery.

Epithelial Inclusion Cyst of the Iris

We describe the clinical presentation, high-frequency ultrasound biomicroscopic characteristics, and pathologic findings associated with a conjunctival inclusion cyst within the iris. The patient had undergone an uncomplicated extracapsular cataract extraction with posterior chamber intraocular lens insertion 9 months prior to presenting with a progressively enlarging iris mass. A clinical examination revealed a solid-appearing white tumor within the midiris stroma, accompanied by limbal-conjunctival hyperemia and anterior chamber inflammation. Ultrasound biomicroscopy revealed an egg-shaped solid iris stromal tumor that displaced the pigment epithelium. The mass was composed of three concentric layers of different echogenicity: a moderately reflective mantle, a less reflective middle zone, and a hyperreflective core. Within 3 days of initiation of topical corticosteroid therapy (prednisolone acetate, 0.5 mg per drop four times daily), the tumor enlarged and induced a plasmoid aqueous and a hypopyon. Histopathologic study revealed a conjunctival inclusion cyst with evidence of acute and chronic inflammation. We have found that the diagnosis of epithelial inclusion cyst within the iris can be aided by an ultrasound evaluation. This case also suggests that it may be preferable to excise these tumors prior to topical corticosteroid treatment.

Atonic pupil after cataract surgery

We report and describe the clinical findings of three patients who developed atonic pupil after uncomplicated extracapsular cataract extraction with posterior chamber intraocular lens implantation. All patients had normally reactive pupils one day postoperatively, but after two weeks, the pupils were dilated and nonreactive to light, accommodation, and miotics. To estimate the incidence of atonic pupil after cataract surgery, we sent a survey on the frequency, clinical features, and possible etiologies of this syndrome to members of the American Society of Cataract and Refractive Surgery. Of the 567 respondents, 60% had seen at least one case of atonic pupil in the past five years; they reported a total of 1543 cases during that time. This is probably a conservative figure since many cases undoubtedly go unnoticed because of a lack of visual disturbance. We believe this condition occurs more frequently than previously reported. The atonic pupil should be recognized as a possible complication of cataract surgery that should be included in the preoperative consent form.

Long-term Survival of Corneal Sutures: Mersilene vs Nylon

OBJECTIVE: To investigate the long-term survival of mersilene corneal sutures and compare it with nylon. STUDY DESIGN: Recall of patients from a randomized study of cataract extraction, after a minimum interval of 2 years following surgery. SETTING: Teaching hospital. PATIENTS: Patients who underwent uncomplicated extra-capsular cataract extraction with lens implantation by a single surgeon through a corneal incision closed with mersilene or nylon. MAIN OUTCOME MEASURES: Symptoms attributable to the corneal suture, presence of giant papillary conjunctivitis (GPC) and condition of the suture. RESULTS: All 16 eligible patients in the mersilene group and 16 (80%) of the nylon group were reviewed. The two groups were similar in age, sex distribution and time from surgery. In the nylon group, three patients were symptomatic and one had GPC, compared to none in the mersilene group. All of the mersilene sutures were intact, compared to only four (25%) of the nylon group ( P = 0.00002). All four of the intact nylon sutures showed visible evidence of degradation whilst none of the mersilene sutures did ( P = 0.0004). CONCLUSIONS: Mersilene corneal sutures have a significantly better long-term survival than nylon. Mersilene should be the preferred material for wound closure following cataract surgery.

Anterior hyaloidal fibrovascular proliferation

Anterior hyaloidal fibrovascular proliferation was first described in phakic eyes with florid proliferative diabetic retinopathy after standard three-port pars plana vitrectomy. Severe vision-threatening complications of this entity are the development of complicated cataracts, vitreous hemorrhage, traction retinal detachment, ciliary body detachment, and finally phthisis bulbi. It was a recent observation that anterior hyaloidal fibrovascular proliferation can occur after uncomplicated extracapsular cataract extraction with an intraocular lens implant in proliferative diabetic eyes. After cataract surgery the course of the disease process seems to be much less severe; however, there is a risk of visual impairment and it may be useful to detect anterior hyaloidal fibrovascular proliferation early to treat it most effectively. The most important differential diagnosis of anterior hyaloidal fibrovascular proliferation after cataract extraction is rubeosis capsulare. Rubeosis capsulare develops with direct spread from iris neovascularization and thus the distinction between the two entities is made by observing whether the neovascularization is visible on the anterior or posterior surface of the posterior lens capsule.

Effects of intraocular lens malposition on binocular single vision in bilaterally pseudophakic patients

To investigate the relationship between intraocular lens (IOL) malposition and quality of binocular single vision following uncomplicated extracapsular cataract extraction and posterior chamber IOL implantation. Fifty-two bilaterally pseudophakic patients were included. The main outcome measures were visual acuity, stereoscopic acuity, horizontal and vertical amplitudes of fusion and heterophoria, tilting angle and decentration amount of the pseudophacos and summation of these values in somewhat vectorial manner to define the total decentration and tilt of IOLS. The mean total horizontal decentration was 0.19 mm and vertical decentration was 0.90 mm, mean total horizontal tilt being 1.55 degrees and vertical tilt 7.52 degrees. The mean stereoscopic acuity was found to be 1020 seconds of arc. Although the stereoscopic acuity threshold increased as decentration and tilt of IOLS increased, only the horizontal tilt was found to be statistically significantly correlated with stereoscopic acuity (pc0.01). The quality of binocular single vision may be affected by IOL malposition in pseudophakic patients. Therefore, when an IOL implantation is planned, the most appropriate IOL design and surgical technique causing least decentration and tilt should be preferred.

Is measuring intraocular pressure necessary on the first post-operative day following uncomplicated cataract surgery?

A prospective study was undertaken to assess whether the level of intraocular pressure (IOP) on the first day after cataract surgery could be estimated by clinical examination only, thereby removing the need for applanation tonometry. A total of 70 patients underwent uncomplicated extracapsular cataract extraction and intraocular lens implantation. The following day a Consultant, Registrar and Senior House Officer were asked to identify those patients with significantly raised IOP (> 27 mmHg) using slit lamp examination only. A fourth examiner, masked to the assessments of the three observers, measured the IOP using the Goldmann applanation tonometer. Pressures of > 27 mmHg by Goldmann tonometry were found in 10 patients (14%) of which 8 (80%) were missed by all three ophthalmologists. Formal measurement of IOP appears a necessary part of the post-operative assessment after uncomplicated cataract surgery.

Preliminary Study of a New Intraocular Method in the Diagnosis and Treatment of Propionibacterium acnes Endophthalmitis Following Cataract Extraction

ABSTRACT Late endophthalmitis, due to Propionibacterium acnes, developed in three patients following uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens (PC-IOL) insertion. Cultures from the capsular bag yielded P. acnes in all three. With topical anesthesia and through an anterior chamber paracentesis, culture specimens were taken from and cfmdamycin irrigated into the capsular bag. Filtered 100% oxygen was introduced into the anterior chamber in two; the third also received an injection of gentamicin and dexamethasone into the capsular bag. After treatment, two patients received oral antibiotics; one received hyperbaric oxygen therapy. Visual acuity was improved and inflammation reduced in all three. However, after treatment, ocular toxic effects due to clindamycin were suspected in one. This approach offers several clear advantages, including topical anesthesia, outpatient management, elimination of the need for vitrectomy, and retention of the intraocular lens (IOL).

Comparison of Acuity, Contrast Sensitivity, and Disability Glare Before and After Cataract Surgery

We assessed vision before and after uncomplicated extracapsular cataract extraction and intraocular lens implantation in 72 symptomatic patients with acuity equal to or better than 20/80 and no other ocular abnormality. Contrast sensitivity was measured with the Pelli-Robson Letter Chart (Metropia Ltd, Cambridge, England) and disability glare was measured under daytime conditions with the Brightness Acuity Tester (Mentor O&O Inc, Norwell, Mass) and under nighttime conditions with a computer-controlled video display. Prior to surgery there was significant disability glare that was not correlated with acuity. There was also a loss in contrast sensitivity that was moderately correlated with acuity (r = -.43; P < .001). Following surgery, most patients' scores returned to normal on all tests. Improvement in disability glare and contrast sensitivity was independent of improvement in acuity. Furthermore, patients with the poorest preoperative vision were as likely to regain normal function after surgery as those with the best preoperative vision.

Incidence of secondary cataract in sulcus versus capsular bag fixation of posterior chamber lenses

We present a retrospective study on the incidence of visually impairing secondary posterior capsule opacification following fixation of an intraocular lens implant either in the ciliary sulcus or the capsular bag. One hundred patients in each group were evaluated 3 1/2 to 3 3/4 years following uncomplicated extracapsular cataract extraction. Only implants with convex-plane optics and forward angulated haptics were used. The incidence of capsular opacification was 20% in eyes with sulcus fixation as opposed to 14% for those with capsular bag fixation. This difference was statistically not significant. The difference in average postoperative interval until development of the secondary cataract (21 months for sulcus, 28 months for capsular bag fixation) or the age of patients with capsular opacification was statistically not significant either. However, it was noted that of the younger patients, between 40 and 50 years at the time of operation, only those with sulcus fixated implants developed secondary cataracts.

Corneal Toxicity With an Antibiotic/Steroid—Soaked Collagen Shield

In response to theClinical Alert1issued by the American Academy of Ophthalmology in November 1990 regarding corneal complications following the use of antibiotic/steroid—soaked collagen shields, we report a complication following the use of a antibiotic/steroid—soaked collagen shield used after surgery to decrease inflammation and prevent infection. Report of a Case. —An 84-year-old white woman underwent an uncomplicated extracapsular cataract extraction with insertion of a posterior chamber intraocular lens in her right eye in September 1990. At the conclusion of the procedure, a 12-hour collagen shield (Bausch & Lomb, Clearwater, Fla) soaked in tobramycin sulfate (40 mg/mL), vancomycin hydrochloride (50 mg/mL), and dexamethasone sodium phosphate (4 mg/mL) was placed on the eye. On the first postoperative day, severe diffuse epithelial and stromal corneal edema was observed, and the intraocular pressure was 10 mm Hg. The patient was treated with 1% topical prednisolone acetate 12 times a day and