Zonular Weakness Research Articles

Forceps-assisted, 10-0 monofilament nylon, suture-guided capsular tension ring insertion in subluxated cataracts.

Capsular tension ring (CTR) and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We would like to describe the use of monofilament 10-0 nylon (MFN)- guided CTR insertion in a subluxated cataractous lens. Here, the MFN is passed through the distal trailing eyelet of the CTR (simple or Morcher's depending on the size of the defect and subluxation) for controlled insertion of the distal eyelet of the CTR beneath the anterior capsulorhexis margin and safe retrieval of CTR in case of an iatrogenic posterior capsular tear during CTR insertion or phacoemulsification.

Концепция стабильной фиксации ИОЛ при авитрии и несостоятельности связочного аппарата хрусталика

Концепция стабильной фиксации ИОЛ при авитрии и несостоятельности связочного аппарата хрусталика

Phacoemulsification and zonular weakness: contribution of the wired capsular tension ring

Phacoemulsification and zonular weakness: contribution of the wired capsular tension ring

Mechanisms of Glaucoma in Exfoliation Syndrome.

The most important characteristic of exfoliation syndrome (XFS) is that it involves a greater risk of developing glaucoma. In comparison with other forms of open-angle glaucoma, exfoliation glaucoma is more resistant to medical therapy and progresses faster. Possible pathologic mechanisms of glaucoma development in XFS comprise: (1) elevated intraocular pressure (IOP) caused by functional impairment of aqueous humor outflow due to deposition of exfoliation material in the trabecular meshwork and trabecular cell dysfunction, (2) XFS-associated connective tissue elastosis leading to structural and functional alterations of the lamina cribrosa which increases the vulnerability toward elevated IOP and development of glaucomatous optic neuropathy, (3) elevated IOP due to closure of the anterior chamber angle accompanied by forward displacement of the crystalline lens due to zonular weakness, (4) presumable primary functional impairment of retinal ganglion cells. In addition to the discovery of lysyl oxidase-like 1, further genetic associations have been identified and knowledge related to XFS etiology and pathophysiology has markedly increased over the past 10 years. Further cell biological investigations navigated by the molecular genetics underlying XFS will eventually lead to a better understanding of the complex mechanisms of exfoliation glaucoma.

Zonular instability in patients with pseudoexfoliative syndrome: the analysis of 1000 consecutive phacoemulsifications

Phacoemulsification (PHACO) is the gold standard of cataract surgery. Сataract surgery in eyes with pseudoexfoliative (PEX) syndrome is associated with increased risk of intra- and postoperative complications. Zonular laxity is one of the main causes of surgical complications.
 Purpose. To assess the degree of zonular weakness in patients with PEX.
 Materials and methods. 1010 eyes (580 eyes with PEX and 430 eyes without it) that underwent consecutive PHACO at the Ophthalmology Department No 5 of the City Multifunctional Hospital No 2 from May 2016 until October 2017 were enrolled in the study. The zonular laxity was assessed preoperatively and intraoperatively.
 Results. Zonular weakness was observed more often in patients with PEX, both at preoperative and intraoperative evaluation (p 0.05). However, in both groups, the percentage of zonular weakness estimated intraoperatively, was several times higher, than that estimated preoperatively. Nevertheless there was no difference in the rate of capsular bag related intraoperative complications between two groups.

This issue of ACTA, printed and electronic

This issue of <i><scp>ACTA</scp></i>, printed and electronic

Intracapsular cataract extraction for the management of dense cataracts and zonular weakness

Purpose: To describe the use of Intracapsular Cataract Extraction (ICCE) with and without concomitant Pars Plana Vitrectomy (PPV) for the treatment of selected cases of dense cataract and zonular weakness. Case Series: This is a retrospective analysis of five eyes of four patients undergoing ICCE during the last eight years. Results and discussion: Five eyes of four patients underwent ICCE. Two patients had traumatic cataracts and amblyopia, one patient (2 eyes) had ectopia lentis associated with homocystinuria. All eyes had dense nuclear sclerotic, mature or hypermature cataracts in addition to generalized zonular weakness. Three eyes underwent combined PPV. One eye underwent concomitant repair of a rhegmatogenous retinal detachment. Three eyes received anterior chamber intraocular lenses. All surgeries were successfully performed without complication, although one eye developed reversible cystoid macular edema following surgery. Three eyes without pre-existing amblyopia experienced excellent post-operative visual acuity (range 20/20 to 20/30) during an average follow-up period of 17 months. Conclusion: ICCE alone or in combination with pars plana vitrectomy is a safe and effective method for removing dense cataracts in the setting of zonular weakness or absence.

Management of angle-closure glaucoma secondary to spherophakia: A report and brief review of treatment options

A 16-year-old girl presenting with chronic headaches had findings of high myopia, uniformly shallow anterior chambers, and spherical crystalline lenses in both eyes with elevated intraocular pressure (IOP) in the left eye. The optic discs were healthy and axial lengths were normal. Antiglaucoma medications were initiated. Inadvertent cycloplegia paradoxically aided control of pressures within 24 h. On review, gonioscopy revealed nonsynechial angle closure. Dilatation revealed no zonulodialysis or subluxation bilaterally. The edge of the lens was clearly seen. A diagnosis of bilateral spherophakia with secondary angle-closure glaucoma in the left eye was made. She underwent sequential phacoemulsification with foldable intraocular lens implantation which adequately controlled her IOPs. Identifying spherophakia when presented with high myopia, raised IOPs and shallow anterior chambers, and documenting peripheral synechiae, subluxation, and zonular weakness may prove crucial in the management of secondary angle-closure glaucoma in such cases.

Supervised resident manual small-incision cataract surgery outcomes at large urban United States residency training program

To examine the outcomes of resident-performed manual small-incision cataract surgery (SICS) in an urban academic setting. Parkland Memorial Hospital, Dallas, Texas, USA. Retrospective case series. Manual SICS was used only in selected cases for which phacoemulsification was expected to be difficult, namely for mature or brunescent cataracts, traumatic cataracts, and pseudoexfoliation syndrome or other causes of zonular weakness. All manual SICS cases performed by resident physicians as the primary surgeon over a 5-year period were reviewed. Postoperative visual acuity, intraoperative complications, and early postoperative complications were the main outcomes measured. For the 52 cases identified, the mean preoperative visual acuity was 2.165 logarithm of the minimum angle of resolution (logMAR)±0.141 (SD) (95% confidence interval) (slightly better than had motion acuity), improving to 0.278±0.131 logMAR (Snellen 20/38) corrected visual acuity postoperatively. Of the 52 cases, the most frequent intraoperative complications were iris prolapse (5 cases [9.6%]) and zonular dialysis (4 cases [7.7%]), with vitreous loss occurring in 1 case (1.9%). The most frequent postoperative complications were cystoid macular edema (3 cases [5.8%]), retained ophthalmic viscosurgical device (2 cases [3.8%]), intraocular lens displacement (2 cases [3.8%]), and microhyphema (2 cases [3.8%]). Although the more advanced wound construction in manual SICS might be challenging to surgeons unfamiliar with the technique, it was a safe and efficacious technique in the hands of learning residents. With several advantages over phacoemulsification, such as cost and ability to remove very dense nuclei, manual SICS will play a valuable role in modern cataract surgery.

Chronic and Intermittent Angle Closure Caused by In-The-Bag Capsular Tension Ring and Intraocular Lens Dislocation in Patients With Pseudoexfoliation Syndrome

A subluxation or dislocation of the intraocular lens (IOL) is a well-known complication after cataract surgery in patients with pseudoexfoliation syndrome (PEX). Capsular tension rings (CTR) are frequently used to prevent postoperative complications caused by zonular weakness. Here we present a series of 7 cases, 2 with intermittent and 5 with acute angle closure caused by a combination of PEX-associated zonular weakness and a resulting unstable capsular bag-CTR-IOL complex. We describe the typical clinical course with elevated intraocular pressure, myopic shift, and shallowing of the anterior chamber in 7 patients with a new type of secondary angle closure. The diagnostic challenges and treatment options are discussed in detail. In all cases, the mechanism of angle closure identified by ultrasound biomicroscopy was an anterior dislocation of the peripheral iris by the capsular bag-CTR-IOL complex. The IOL was removed together with the capsular bag and the CTR and replaced by an iris-fixated IOL in all cases. We present a new type of secondary angle closure caused by an anterior dislocated capsular bag-CTR-IOL complex. The cause of both, this atypical presentation and the ineffectiveness of the laser peripheral iridotomy is the large diameter CTR. Therefore CTR implantation might also be the source of late postoperative complications. If a secondary angle closure associated with PEX and unstable capsular bag-CTR-IOL complex is encountered, IOL explantation and replacement by an iris-fixated IOL is a simple and effective treatment option.

Assessment of a novel pinhole supplementary implant for sulcus fixation in pseudophakic cadaver eyes

PurposeTo evaluate a novel small-aperture supplementary implant that applies the principle of pinholes for management of irregular astigmatism, in postmortem human eyes.MethodsPseudophakic human cadaver eyes were imaged by anterior segment optical coherence tomography (AS-OCT) to assess position of the in-the-bag intraocular lens (IOL). Eyes were prepared as per the Miyake-Apple technique. Two versions of the supplementary implant (open-loop and tripod designs) were then inserted into the sulcus of each eye. Evaluations under AS-OCT and from anterior and posterior views of the anterior segment were used to assess IOL fixation, centration, tilt, and interlenticular distance (ILD). This experimental study has been conducted in John A. Moran Eye Center, University of Utah.ResultsNine eyes were selected, with various sizes, primary IOL materials/designs, and Soemmering's ring formation. The open-loop model exhibited a mild degree of decentration and tilt in 2 eyes with zonular dehiscence. Mild decentration and tilt of the tripod were observed in 4 eyes; in 1 additional eye it was centered but mildly tilted. Three eyes with zonular dehiscence had one of the closed loops of the tripod located posteriorly to the ciliary processes. In all cases, an ILD was observed between the lenses (open loop: 0.65±0.13 mm; tripod: 0.41±0.12 mm).ConclusionsIt is important to take into account anatomical aspects related to ciliary sulcus fixation of supplementary IOLs. Both designs evaluated, exhibited appropriate centration and ILD. The open-loop design had less risk of tilt in association with haptics protruding posteriorly through areas of zonular weakness.

Cataract surgery outcome in patients with non-glaucomatous pseudoexfoliation.

Aim. To study the outcome of cataract surgery in eyes with pseudoexfoliation without signs of glaucoma. Methods. This prospective study was done over nine months on patients with pseudoexfoliation undergoing small incision cataract surgery. Only patients with normal intraocular pressure (Central Corneal Thickness Corrected), normal cup disc ratio and open angles were included. Patients on anti-glaucoma medication were excluded. Patients underwent surgery performed by a single senior surgeon. Intraoperative and postoperative day (POD) 1 findings were noted. Results. The mean age of the patients was 61.60 years +/ - 10.21 years. Males were 46% (n=16). Right eye was operated upon in 60% of the cases (n=21). The mean pupil dilation was 5.1 mm +/ - 1.47 mm. The postoperative day 1 visual acuity of the patients was logMar 1.02 +/- 0.64 and the mean POD 1 intraocular pressure was noted to be 26.23 mmHg +/ - 11.40 mmHg. Five cases had a zonular dialysis intraoperatively due to weak zonules. 11 cases had high anterior chamber reaction of 2+ or more. Four cases had unavoidable sphincter tears and two cases had iridodialysis superiorly during nucleus delivery. Conclusions. Intraoperative complications should be anticipated in patients with pseudoexfoliation even without glaucomatous changes due to poor pupillary dilation and zonular weakness. First postoperative day visual acuity in pseudoexfoliation patients undergoing cataract surgery was found to be low due to severe anterior chamber inflammation causing elevated intraocular pressure and corneal edema. Abbreviations. POD = Postoperative day, PEX = Pseudoexfoliation syndrome, LOXL 1 = Lysyl oxidase-like 1, IOP = Intraocular pressure, AC = Anterior chamber, IOL = Intraocular lens.

Limits for the indication of multifocal lenses based on the contrast sensitivity function

SummaryMultifocal IOLs are more often responsible for lower contrast sensitivity (CS) than monofocal IOLs, especially in mesopic light conditions. Thus, multifocal IOLs are contraindicated in many ocular diseases, which are characterized by decreased contrast sensitivity function. They included irregular astigmatism, Fuchs dystrophy, and many retinal diseases affecting macular function like retinitis pigmentosa, Stargardt disease, diabetic retinopathy, age‐related macular degeneration, epiretinal membrane, and many optic nerve disorders. IOL decentration and tilt lead to decreased contrast sensitivity, aberrations, and ultimately decreased visual acuity, thus zonular weakness, esp. when severe, should be regarded as absolute or relative contraindication to choosing a multifocal IOL. Since contrast sensitivity is found to be most affected in eyes with aberrations and implanted multifocal IOLs, increased aberrations are relative contraindications for multifocal IOL implantation. It was proved that patients with the aspheric multifocal IOL had significantly better contrast visual acuity than patients with the spherical multifocal IOL.

Cataract surgery outcomes and complications in retinal dystrophy patients

ObjectiveTo investigate intraoperative complications, postoperative findings, and visual acuity outcomes in patients with retinal dystrophy after cataract surgery. DesignRetrospective chart review at an academic tertiary referral centre. ParticipantsThirty eyes from 18 patients with retinitis pigmentosa and other retinal dystrophies (Usher syndrome, Refsum disease, and Leber congenital amaurosis) who underwent cataract surgery were identified by searching the electronic medical record system from January 2010 to September 2015 for all patients treated by a single physician with billing codes for retinal dystrophy and cataract surgery. MethodsCases were reviewed to determine indication for surgery, intraoperative complications, postoperative findings, preoperative visual acuity, 1-month postoperative visual acuity, and patient subjective satisfaction. ResultsMean best-corrected visual acuity significantly improved after cataract surgery, from 1.09 ± 0.69 preoperatively to 0.614 ± 0.448 at 1 month postoperatively, on logMAR scale (p = 0, Wilcoxon test). The most common postoperative finding was posterior capsule opacification in 20 eyes (66.7%). Visually significant cystoid macular edema occurred in 4 eyes (13.3%) despite the postoperative eye drop regimen. Patient satisfaction at 1 month postoperatively was noted as 93.3% (28 eyes) and attributed mostly to improved central vision and reduced glare symptoms. ConclusionsPatients with visually significant cataract in association with retinal dystrophy have significantly improved best-corrected visual acuity after cataract surgery and report subjectively improved visual functioning. This study confirms that several risks factors are greater in patients with retinal dystrophy, including zonular weakness, posterior capsular opacification, and cystoid macular edema, compared with the general cataract population.

New capsular tension segment with 2-point fixation for zonular weakness

We describe clinical applications and surgical techniques for a new type of capsular tension segment (CTS) for use during cataract surgery. The Ambati CTS is distinguished from other CTS devices by having 2 eyelets close to each other, which allowsit to distribute tension to 2 points, avoiding too much stress at a single point on the anterior capsulotomy, which prevents peaking of the capsulorhexis, and potentially reducing the risk for anterior capsule tear. Two of these CTS devices could possibly be used to provide 4-point fixation of a capsular bag in eyes with near-complete zonular instability. We describe 4cases and 2 surgical techniques for implanting the new CTS, 1 technique in an adult patient with zonular weakness secondary to trauma and the other in 3 children with subluxated lenses due to Marfan syndrome.

Objective classification of zonular weakness based on lens movement at the start of capsulorhexis.

PurposeTo quantify zonular weakness based on lens movement at the start of continuous curvilinear capsulorhexis (CCC) and establish a classification system for it.SettingKozawa Eye Hospital and Diabetes Center, Mito, Japan.DesignRetrospective interventional case series.MethodsWe examined 402 consecutive eyes of 316 patients who underwent CCC, phacoemulsification and aspiration (PEA), and intraocular lens (IOL) implantation. The movement of the lens capsule was measured using images from video recordings of the CCC procedure. Zonular weakness was classified based on the shifted distance: Grade I, less than 0.20 mm; Grade II, 0.20–0.39 mm; and Grade III, greater than 0.40 mm. For each of these grades, we examined the use of the capsule stabilization device during PEA, the surgical procedure for lens removal, and IOL fixation.ResultsWe classified 276 eyes (68.6%) as Grade I, 102 eyes (25.4%) as Grade II, and 24 eyes (6.0%) as Grade III. As the grade increased, the use of the capsule stabilization device in PEA and scleral suture fixation of IOL increased.ConclusionsZonular weakness was quantified by measuring the movement of the lens capsule. An objective classification of zonular weakness based on lens movement may be useful for selecting the appropriate device and procedure during cataract surgery.

Outcomes of intraocular lens implantation in the absence of capsular support: a review of current literature

to classify and comparatively analyze the latest published data on the outcomes of various kinds of complicated cataract surgery. Analysis of available literature on the subject of research published in 2003-2016. The method of sutured scleral fixation of the intraocular lens (IOL) is the most fully covered in the current literature. It has been used long enough and is, therefore, well tested. Its typical complications include sutures degradation, hemorrhage, and inflammation. Sutureless fixation of the IOL, which has become more common in recent years, is free of complications associated with degradation of the sutures. However, studies on the long-term results of this technique are few and most of them were conducted in a small clinical material. Basing on the present analysis, one may conclude that at the current level of surgery, sutureless scleral and iridal fixation of the IOL is more preferable in terms of possible postoperative complications.

Intraoperative and postoperative complications of phacoemulsification in cataract eyes with pseudoexfoliation syndrome

Introduction/Objective. Pseudoexfoliation syndrome (PEX) is an age-related systemic disorder characterized by deposition of fibrillary white flaky material mainly on the lens capsule, corneal endothelium, zonules, ciliary body, iris, and pupillary margin. Zonular weakness progressively increases along with the hardness of the lens, patient?s age, and the presence of glaucoma. The objective of the study is to compare the intraoperative and postoperative complications of phacoemulsification in cataract eyes with PEX with cataract eyes without PEX. Methods. The study enrolled 300 eyes with consequently operated senile cataract and PEX and 300 consequently operated eyes with cataract without PEX who underwent phacoemulsification performed by one experienced surgeon (single-surgeon series). A complete ophthalmological examination of all patients was performed preoperatively, as well as on the first, seventh, and 180th day postoperatively. Results. Significant statistical differences between the observed groups were the following: patients with PXF were older (74.2 ? 8; range 56?82 years vs. 68.1 ? 9.6; range 56?79 years), had smaller pupil diameter, and higher intraocular pressure (IOP) preoperatively (16.1 ? 4.1 vs. 13.8 ? 3.7 mmHg). There were no differences between the groups regarding intraoperative complications. Early postoperative complications were a significant rise of IOP (33 vs. six patients; p &lt; 0.001), more frequent postoperative corneal edema (36 vs. 21 patients; p &lt; 0.036), and anterior chamber inflammation (17 vs. seven patients; p &lt; 0.037) in the PEX group, comparing to the control group. The significant late postoperative complication was elevated IOP (24 vs. five patients; p &lt; 0.0002) in patients with PEX. Conclusion. In the hands of an experienced and careful surgeon, phacoemulsification is a safe and beneficial surgery to treat cataract with associated pseudoexfoliation. The greatest problem a surgeon faces is a narrow pupil and zonule instability, and difficulty in recognizing eyes that are particularly at risks, such as those having glaucoma and phacodonesis.

Efficacy of Primary Posterior Curvilinear Capsulorhexis in Adults

Posterior capsular opacification(pco) is the most frequent complication of cataract surgery anddevelops from residual lens epithelial cells that undergo proliferation,migration,metaplasia and differentiation in the capsular bag after cataract surgery.patients with PCO have decreased visual visual acuity, loss of contrast sensitivity, and in some cases, PCO precludes examination of the posterior segment. The incidence of PCO is reported to be 20-50% 5 years after cataract surgery in the general population and has been reported to occur in 100% of pediatric patients. Recently, primary posterior capsulorhexis (PPCC) has been proposed to prevent PCO in adults. The PPCC technique is frequently used in children with or without anterior vitrectomyto prevent posterior capsule opacification (PCO) but is rarely used in adults. In PPCC, the central portion of the posterior capsule is removed during cataract surgery to prevent equatorial LEC migration toward the visual axis. Aim: The aim of the current study was to report the long-term efficacy and safety of phacoemulsification and manual phaco with posterior chamber intra ocular lens implantation combined with PPCC in adult patients with cataract. Materials And Methods: In an interventional case series 100 patients underwent cataract surgery combined with PPCC at Rajiv Gandhi Institute of Medical Sciences Kadapa, Andhra Pradesh from August 2014 to June 2016. Informed consent was obtained from all patients preoperatively. Only adult patients who underwent cataract surgery and PPCC for age-related cataract were included the study. Inclusion Criteria: Although we do not routinely perform PPCC during cataract surgery in adults, it is performed for cases with residual posterior capsule opacification despite careful polishing. Excleusion Criteria: Patients with glaucoma, uveitis, zonular weakness, and proliferative diabetic retinopathy were excluded in this study. Patients with clear posterior capsule were also excluded. Keywords:posterior capsular opacification, Nd: YAG capsulotomy, phacoemulsification, manualphaco, intra ocular lens, and primary posterior capsulorhexis

Management of Severely Subluxated Cataracts Using Femtosecond Laser–Assisted Cataract Surgery

To assess the role of femtosecond laser technology in the management of severely subluxated cataracts. Retrospective, interventional case series. All eyes with subluxated cataract seen between July 2012 and June 2015 were assessed for suitability for femtosecond laser-assisted cataract surgery, with the use of capsular tension devices. Participants with subluxated cataracts of at least 6 clock hours of zonular weakness were included in the study. Data collected included patient demographics, preoperative and postoperative best-corrected visual acuity (BCVA), nuclear density, extent of zonular weakness, completeness of capsulotomy, and complications. Poor visual outcome was defined as BCVA of worse than 20/40. Main outcome measure was the retention of the capsular bag. Of the 72 eyes with subluxated cataracts undergoing surgery during the study period, 47 eyes of 47 patients were eligible for analysis. Mean age of the patients was 60.7 years (standard deviation [SD] 13.2 years). The majority were male (32, 68.1%) and Chinese (38, 80.8%). The mean duration of follow-up was 8months (SD 5.6months). The main identifiable cause of lens subluxation was trauma (11 eyes). Almost two thirds (30 eyes) had more than 9 clock hours of zonular weakness. Seventy percent of cataracts (33) were nuclear sclerosis grade 3 and above. The capsular bag was preserved in 43 eyes (91.5%). The intraocular lens was stable and centered at the last follow-up in all these 43 eyes. An anterior capsule tear occurred in 6 eyes, all of which had cataracts of nuclear sclerosis grade 3 and above, with posterior extension occurring in 3 eyes. Primary posterior capsule rupture occurred in 1 eye. At 1month 37 eyes (80.4%) had a BCVA of 20/40 or better. There was significant improvement in BCVA at 1month (mean of 0.92 logMAR units [SD 0.88] to 0.22 [SD 0.38] [P < .001, paired samples t test]), which was maintained at 1 year. Selected cases of severely subluxated cataracts may be managed using femtosecond laser technology to perform the capsulotomy and nuclear fragmentation, with successful preservation of the capsular bag in 90% of eligible cases, especially in eyes with soft cataracts.