Complications of intraocular lenses. A historical and histopathological review

Anterior Segment Optical Coherence Tomography in Uveitis-Glaucoma-Hyphema Syndrome

PURPOSE

Uveitis-Glaucoma-Hyphema (UGH) syndrome results from contact between the intraocular lens (IOL) and the iris or ciliary body, leading to uveal structure erosion and blood-aqueous barrier breakdown. Treatment involves various drugs, with IOL removal often being necessary. Diagnosis relies on clinical signs, but imaging techniques like ultrasound biomicroscopy (UBM) or anterior segment optical coherence tomography (AS-OCT) are crucial. AS-OCT accurately depicts IOL position and potential contact, emerging as a primary alternative to UBM in the diagnosis. Our study aimed to correlate AS-OCT findings with clinically detectable iris atrophy in pseudophakic patients with IOL-iris chafing and UGH syndrome.

METHODS

The study retrospectively analyzed patients diagnosed with UGH syndrome presenting at the Ocular Immunology Unit of Reggio Emilia, Italy, from January 2019 to August 2023. Patients' data were collected. Ophthalmological exams and imaging were performed. The peephole sign in AS-OCT images was evaluated. Statistical analyses were conducted, with a significance level of p ≤ 0.05.

RESULTS

The study reviewed 22 eyes of 22 patients with UGH syndrome. Four eyes were excluded, leaving 18 patients (8 females, 10 males). Common misdiagnoses included idiopathic anterior uveitis (55.5%) and herpetic anterior uveitis (16.7%). All patients had iris transillumination defects, mostly focal (77.8%). AS-OCT revealed IOL chafing in all the eyes, with peephole sign correlation. More peephole signs occurred with IOL in the sulcus (p-value = 0.08).

CONCLUSION

The study recommends AS-OCT for UGH syndrome confirmation and UBM when IOL-iris chafing is not observed on AS-OCT scans.

Tonic ErbB signaling underlies TGFβ-induced activation of ERK and is required for lens cell epithelial to myofibroblast transition

Fibrosis is a major, but incompletely understood, component of many diseases. The most common vision-disrupting complication of cataract surgery involves differentiation of residual lens cells into myofibroblasts. In serum-free primary cultures of lens epithelial cells (DCDMLs), inhibitors of either ERK or of ErbB signaling prevent TGFβ from upregulating both early (fibronectin) and late (αSMA) markers of myofibroblast differentiation. TGFβ stimulates ERK in DCDMLs within 1.5 h. Kinase inhibitors of ErbBs, but not of several other growth factor receptors in lens cells, reduce phospho ERK to below basal levels in the absence or presence of TGFβ. This effect is attributable to constitutive ErbB activity playing a major role in regulating the basal levels pERK. Additional studies support a model in which TGFβ-generated reactive oxygen species serve to indirectly amplify ERK signaling downstream of tonically active ErbBs to mediate myofibroblast differentiation. ERK activity is in turn essential for expression of ErbB1 and ErbB2, major inducers of ERK signaling. By mechanistically linking TGFβ, ErbB, and ERK signaling to myofibroblast differentiation, our data elucidate a new role for ErbBs in fibrosis and reveal a novel mode by which TGFβ directs lens cell fate.

Microscopic analysis of preinsertion cutting modalities on custom, flexible iris prostheses

PURPOSE

To determine the induced edge effects of different clinically used device postmanufacture modification styles and modalities on custom iris implants.

SETTINGS

An academically affiliated multispecialty private practice group and an academic medical center.

DESIGN

Laboratory study.

METHODS

Sample custom iris prostheses were cut using patterns, blades, and surgical instruments described in the literature. The cut edges were evaluated with slitlamp microscopy, light microscopy, and scanning electron microscopy.

RESULTS

Disposable blades yielded smoother cuts than scissors. Trephine blade brand significantly affected the cut surface smoothness of the silicone matrix. Meshwork-embedded prostheses had some irregular sharp edges where the mesh fibers were cut with all modalities, although these were worse with scissors and one tested trephine brand compared with the other. Pseudoiridectomies and scissor cuts created sharp points and corners in the device periphery.

CONCLUSIONS

Postmanufacture modifications of iris implants should be minimized. The cut margins of the fiber-free implants have fewer sharp edges and may be preferable for sulcus placement. In-the-bag device placement may mitigate clinical impact of sharp edges and corners. These practices may help to minimize inflammatory sequelae postimplantation.

Occult Uveitis-Glaucoma-Hyphema Syndrome Caused by PCIOL with Peripheral Capsular Tear

Introduction

Uveitis-glaucoma-hyphema (UGH) syndrome is an infrequent but severe complication following intraocular lens implantation, characterized by anterior chamber inflammation and elevated intraocular pressure (IOP). This report presents a rare case of late-onset UGH syndrome induced by a well-positioned 1-piece posterior capsular intraocular lens (PCIOL) with a bulb of the haptics extruding through a peripheral capsular tear in a 90-year-old female, 17 years post-cataract surgery.

Case Presentation

The patient presented with persistent blurred vision, recurrent anterior uveitis, and uncontrolled IOP despite medical therapy. Extensive evaluation, including ultrasound biomicroscopy, failed to identify the underlying cause, necessitating surgical intervention to control IOP. During concurrent goniotomy and canaloplasty, a PCIOL haptics was discovered protruding through a peripheral capsular tear, establishing the diagnosis. Following PCIOL-haptic amputation and goniotomy and canaloplasty, the patient experienced significant improvement in symptoms and IOP control, with complete resolution of UGH syndrome.

Conclusion

This case highlights the necessity of considering atypical causes in persistent postoperative uveitis and IOP elevation and emphasizes the role of surgical intervention in managing complex cases.

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.

Recent Advances of Intraocular Lens Materials and Surface Modification in Cataract Surgery

Advances in cataract surgery have increased the demand for intraocular lens (IOL) materials. At present, the progress of IOL materials mainly contains further improving biocompatibility, providing better visual quality and adjustable ability, reducing surgical incision, as well as dealing with complications such as posterior capsular opacification (PCO) and ophthalmitis. The purpose of this review is to describe the research progress of relevant IOL materials classified according to different clinical purposes. The innovation of IOL materials is often based on the common IOL materials on the market, such as silicon and acrylate. Special properties and functions are obtained by adding extra polymers or surface modification. Most of these studies have not yet been commercialized, which requires a large number of clinical trials. But they provide valuable thoughts for the optimization of the IOL function.

Fifteen years of IOL exchange: indications, outcomes, and complications

PURPOSE

To report the indications, frequency, and outcomes regarding intraocular lens (IOL) exchange in 2 university hospital tertiary referral settings over a period of 15 years.

SETTING

Ophthalmology departments of the University Hospital Antwerp and the University Hospital Leuven, Belgium.

DESIGN

Retrospective cross-sectional study.

METHODS

In this retrospective study, included were patients who underwent an IOL exchange between 2002 and 2017. Patient demographics, surgical indication, comorbidities, visual outcomes, and complications were reported. Patients who underwent IOL repositioning or add-on IOL implantation or extraction, and patients who were left aphakic, were excluded.

RESULTS

Included in the study were 492 eyes. The mean age was 66.0 ± 13.3 years (range 19-91 years). The mean time between primary surgery and IOL exchange was 54.61 ± 67.07 months (range 0-343 months). Primary indication for explantation was IOL opacification, and the most common ophthalmic comorbidity was a previous history of vitreoretinal surgery. Preoperatively, the mean uncorrected visual acuity (UCVA) and corrected distance visual acuity (CDVA) were 0.47 ± 0.27 (range 0-1) and 0.61 ± 0.32 (range 0-1.2), respectively. Postoperative UCVA and CDVA was 0.7 ± 0.3 (range 0-1.2) and 0.8 ± 0.28 (range 0.05-1.6), respectively. The increase in both CDVA and UCVA was statistically significant (P < .001, paired t test). The most common complication perioperatively was vitreous prolapse, which occurred in 61 eyes (16%).

CONCLUSIONS

IOL exchange is a challenging yet valuable treatment option for a wide spectrum of problematic IOL outcomes. The most common indication remains IOL opacification, although IOL dislocation and patient dissatisfaction are increasing as indications.

Retropupillary Iris-Claw Intraocular Lenses: A Literature Review

Retropupillary iris-claw intraocular lenses (ICIOLs) have been increasingly chosen by surgeons nowadays as a primary or secondary procedure of IOL implantation in eyes with insufficient capsular or zonular support. They have gained popularity due to their simple fast technique, favourable functional outcomes, and safety. The transition in the ICIOL fixation from prepupillary to a more biologically appropriate retropupillary position and change in the optic design from biconvex to convex-concave have provided better visual outcomes and improved safety. A peer-reviewed literature search was conducted in Medline (PubMed), Embase, and Cochrane Library using the keywords "retropupillary iris claw" and "iris claw". The search yielded 310 articles that were screened. Forty-three articles on retropupillary ICIOLs were finally found to be relevant and reviewed in full-text versions. The functional outcomes following retropupillary implantation of ICIOLs have been acceptable in eyes with no ocular co-morbidities otherwise. However, the indications for surgery may affect the outcomes. The major postoperative complications directly associated with ICIOLs include pupil ovalization and redislocation. Nevertheless, the rate of disenclavation depends on the experience and skill of the surgeon. This review is based on a literature review, and it focuses on the preoperative evaluation, surgical technique, postoperative outcomes, and associated complications. Prospective randomized trials with a larger sample size and longer follow-up are needed for comparison with other techniques of IOL fixation and confirmation of long-term safety profile.

Uveitis-Glaucoma-Hyphema Syndrome: Clinical Features and Differential Diagnosis

Purpose: to study the clinical features of uveitis-glaucoma-hyphema (UGH) syndrome, particularly those useful for a differential diagnosis from unilateral hypertensive acute anterior uveitis.Methods: A retrospective chart review was conducted on the clinical features of 9 patients with UGH syndrome. These features were then compared with those detected in 50 patients with unilateral hypertensive acute anterior uveitis.Results: Fine and pigmented keratic precipitates (p = .0002 and p = .00004, respectively), iris atrophy (p = .0122), hyphema and vitreous opacities > 2+ (p = .0003), and cystoid macular edema (p = .009) were statistically associated with UGH syndrome. These clinical signs show a high specificity, ranging from 58 to 100%; the presence of pigmented keratic precipitates in the setting of a unilateral acute hypertensive anterior uveitis has a sensitivity and specificity of 89% and 84%, respectively.Conclusion: In patients operated on for cataract, UGH syndrome can be differentiated from unilateral hypertensive acute anterior uveitis considering specific clinical signs.

Seventy-one cases of uveitis-glaucoma-hyphaema syndrome

PURPOSE

To assess Uveitis-Glaucoma-Hyphaema syndrome (UGH syndrome) with focus on resolution, glaucoma development and risk factors.

METHODS

This retrospective case-control study with a cross-sectional component was performed to compare three groups with 71 patients each: UGH syndrome, dislocated intraocular lens (IOL) without UGH syndrome and ordinary pseudophakia. Main outcome measures were resolution of the UGH syndrome, best-corrected visual acuity (BCVA) and the need of glaucoma therapy. We also assessed the IOL-iris contact signs and the use of blood thinners.

RESULTS

Uveitis-Glaucoma-Hyphaema (UGH) syndrome resolved in 77 % of patients who underwent various kind of IOL surgery. Intraocular pressure (IOP) decreased and BCVA improved in the operated cases (p = 0.02 and p < 0.001, respectively), but not in the cases treated conservatively. Intraocular pressure (IOP) ≥22 mmHg at the first haemorrhage predicted the need of glaucoma therapy after UGH syndrome resolution (p = 0.002, area under the curve = 0.8). Fifty-one per cent of patients without preexisting glaucoma needed glaucoma therapy after UGH syndrome resolution. Pseudophacodonesis was seen more frequently in the UGH group than in the ordinary pseudophakia group (p = 0.001). Iris defects were not more frequent in the UGH group than in the Dislocated group but the types of defects differed (p < 0.0001). Blood thinners were not more frequent in UGH.

CONCLUSION

In UGH syndrome, the results are better with surgical intervention than with conservative treatment, but surgery does not guarantee resolution. Pseudophacodonesis is a risk factor for UGH syndrome, but blood thinners are not, and iris defects are not specific to UGH syndrome. A high IOP at the first haemorrhage increases the risk for needing subsequent IOP-lowering therapy.

Ten-year trends in the incidence, clinical profile and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and sutureless, glueless and flapless scleral fixation of intraocular lenses

PURPOSE

To evaluate the frequency and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and scleral fixation of intraocular lens.

METHODS

We evaluated patients undergoing a sutureless, glueless, flapless technique of scleral fixation of intraocular lenses (SFIOL) implantation for various causes of aphakia and documented the clinico-demographic data, microbiological profile and final outcome after acute endophthalmitis in this cohort of eyes.

RESULTS

The frequency of suspected acute endophthalmitis diagnosed post-surgery was 0.112% (4/3541 eyes), with culture-positive endophthalmitis frequency being 0.028% (1 eye), showing growth of Pseudomonas aeruginosa. Mean age of patients with endophthalmitis was 51.75 ± 9.28 years, and mean interval between surgery and acute endophthalmitis presentation was 10.25 ± 9.6 days. Patients were managed with intravitreal antibiotics with or without core vitrectomy. Visual acuity of patients increased from baseline 1.43 ± 0.32 logMAR (Snellen equivalent = 6/150) to 0.79 ± 0.16 logMAR (Snellen equivalent = 6/36) after an average follow-up of 11 ± 2 weeks.

CONCLUSION

Endophthalmitis is a rare complication following SFIOL surgery, and all ophthalmic surgeons must be aware of this inadvertent possibility, since SFIOLs are gaining wider acceptability recently. Moreover, these cases of endophthalmitis may show a different pattern of microorganisms than post-cataract surgery endophthalmitis; however, with prompt diagnosis and effective timely management, favorable outcomes can be achieved.

Clinical Outcomes and Lens Constant Optimization of the Zeiss CT Lucia 602 Lens Using a Modified Yamane Technique

Purpose

To report the clinical and refractive outcomes of a modified Yamane technique for scleral fixation of the CT Lucia 602 lens.

Design

Retrospective case series.

Patients

One hundred twenty-one eyes with dislocated posterior chamber lens implants, surgical aphakia, subluxed crystalline lenses, capsular tear, anterior chamber, or iris sutured posterior chamber lens intolerance were included.

Methods

Secondary implantation of the Zeiss CT Lucia 602 lens was performed by a single surgeon using a modified Yamane technique employing a single needle, rather than the double-needle approach. One hundred twelve eyes underwent simultaneous 3 port pars plana vitrectomy and 9 eyes had previously undergone posterior vitrectomy surgery. Exclusion criteria were age <18, simultaneous glaucoma or corneal procedures, staged corneal transplantation, and follow-up <30 days.

Main Outcome Measures

A paired t-test was used to compare pre- and post-operative corrected distance visual acuity (CDVA), the mean predictive error, and the mean absolute predictive error between the manufacturer’s and optimized constants for Hoffer Q, Holladay I, and SRK/T. Complication rates were reported.

Results

One hundred twenty-one consecutive eyes with a mean follow-up of 237 days were included. The pre-operative CDVA was 0.871 ± 0.785 logMAR (mean ± standard deviation, Snellen equivalent 20/149), which improved to 0.401 ± 0.608 (Snellen equivalent 20/50) post-operatively. In 109 eyes with reliable postoperative refractions, the mean predictive refractive error (D) ± std was +0.74 ± 1.37 for Hoffer Q, +0.66 ± 1.41 for Holladay 1, and +0.47 ± 1.49 for SRK/T (p<0.05). Refractive outcome analysis yielded a mean optimized personalized anterior chamber depth (pACD) of 5.69, Surgeon Factor of 1.79, and A constant of 118.56. Vision-limiting complications occurred in 11 eyes (9.1%).

Conclusion

Scleral fixation of the CT Lucia 602 lens using a single-needle modification of the Yamane technique resulted in very good visual acuity, predictable postoperative refractive errors, but some vision-limiting complications in this heterogeneous group of eyes with significant comorbidities.

[Characteristics and management of Uveitis-Glaucoma-Hyphema syndrome]

INTRODUCTION

Uveitis-Glaucoma-Hyphema syndrome (UGH) is caused by mechanical chafing of anterior segment structures by an intraocular lens, especially an anterior chamber lens. The objective of this study was to characterise the clinical course and risk factors of UGH syndrome at a time when posterior chamber implantation is the gold standard.

PATIENTS AND METHODS

This was a retrospective study of 30 cases of UGH syndrome managed between January 2014 and September 2018. Data from the initial clinical examination, the type of implant involved and the clinical management were analysed.

RESULTS

Thirty eyes of 28 patients were included. Intra ocular lenses were iris-sutured (15/30, 50 %), in the bag (6/30, 20 %), scleral-fixated (4/30, 13.3 %), in the ciliary sulcus (3/30,10 %) or "in and out" (2/30, 6.7 %). Initial management was medical (18 eyes) or surgical (12 eyes). Surgical procedures were explantation (n=4), IOL repositioning (n=7) or trabeculectomy (n=1). Recurrences occurred with medical treatment (9/18), but not in the surgical group (p=0.02). Ocular hypertension became chronic in 19 cases out of 30 (63.3 %).

CONCLUSION

UGH syndrome can be caused by any type of pseudophakic lens. An intraocular lens in the bag should not rule out the diagnosis. Despite the decreasing popularity of anterior chamber intraocular lens implantation, UGH syndrome remains a current condition and must be recognised in order to adapt therapeutic management.

microRNA-378a Regulates the Reactive Oxygen Species (ROS)/Phosphatidylinositol 3-Kinases (PI3K)/AKT Signaling Pathway in Human Lens Epithelial Cells and Cataract

Background

Cataract is associated with increased apoptosis of the epithelial cells of the ocular lens. Previous studies have shown that microRNA-378a (miR-378a) has a role in the development of cataract, but the molecular mechanisms remain unclear. This study aimed to investigate the effects of miR-378a in human lens epithelial cells (HLECs) in vitro and normal lens tissues and cataract tissues.

Material/Methods

HLECs were grown in culture. Quantitative reverse transcription polymerase chain reaction (RT-qPCR) and Western blot were used to examine gene expression levels. The MTT and TUNEL assay measured cell growth and apoptosis. Changes in the fluorescence ratio of ethidium to dihydroethidium (E: DHE) and in 6-carboxy-2′,7′-dichlorodihydrofluorescein diacetate (C-H₂DCFDA) were used to detect superoxide (O₂⁻) and hydrogen peroxide (H₂O₂). The expression levels of miR-378a and the superoxide dismutase 1 gene (SOD1) were measured in normal human lens tissues and cataract tissues.

Results

Upregulation of miR-378a reduced the expression of SOD1. Levels of O₂⁻ were upregulated and H₂O₂ was slightly down-regulated by miR-378a. The use of a miR-378a mimic suppressed cell growth and enhanced apoptosis of HLECs, which were reversed by the use of a miR-378a inhibitor. SOD1 overexpression rescued the miR-378a-induced phenotypes of HLEC cells. Treatment with the PI3K inhibitor, LY294002, reversed miR-378a and ROS-regulated proliferation and apoptosis of HLEC cells. Also, miR-378a was upregulated, and SOD1 was down-regulated in human cataract tissues.

Conclusions

In HLECs, expression of miR-378a regulated ROS and PI3K/AKT signaling, and miR-378a was upregulated, and SOD1 was down-regulated in human cataract tissue.

Edge profile of commercially available square-edged intraocular lenses: Part 2

PURPOSE

To analyze the sharpness of the posterior optic edge and edge thickness of intraocular lenses (IOLs) marketed with a square-edged profile.

SETTING

University of Brighton and Brighton and Sussex University Hospitals NHS Trust, Brighton, England.

DESIGN

Laboratory study.

METHODS

Fourteen square-edged 20.0 diopter IOLs were analyzed, including 9 hydrophobic IOLs (AF-1, AF-1 iSert, Clareon, EyeCee One Crystal, CT Lucia, Envista, EyeCee One, Vivinex iSert, and RayOne Hydrophobic) and 5 hydrophilic IOLs (Asphira, CT Asphina, Incise, Synthesis, and RayOne Hydrophilic). All the IOLs were scanned following a previously published standardized technique using environmental scanning electron microscopy. The posterior optic edges were scanned at a magnification of ×500 and ×200 to measure the radius of curvature of the posterior optic edges and the optic edge thickness.

RESULTS

The radius of curvature of the posterior optic edges ranged from 4.6 to 20.6 μm. Except for the Incise IOL (7.7 μm), all hydrophilic IOLs (Synthesis [10.6 μm], Asphira [13.7 μm], RayOne Hydrophilic [14.0 μm], CT Asphina [13.7 μm]) had a radius of curvature greater than 10.0 μm. For the hydrophobic IOLs, the radius of curvature was less than 10.0 μm for the Clareon (7.9 μm), EyeCee One Crystal (4.7 μm), Vivinex iSert (7.6 μm), and CT Lucia (4.6 μm), and greater than 10.0 μm for the Envista (19.7 μm), EyeCee One (13.7 μm), AF-1 iSert (19.7 μm), AF-1 (19.7 μm) and the RayOne Hydrophobic (20.6 μm). The Vivinex iSert (150.5 μm) and the Incise (218.2 μm) were the thinnest IOLs, and the RayOne Hydrophobic (375.8 μm) and RayOne Hydrophilic IOLs (477.1 μm) were the thickest of the hydrophobic and hydrophilic IOLs, respectively.

CONCLUSIONS

Commercially marketed square-edged IOLs still differed in the sharpness of the posterior optic edge. More hydrophobic IOLs have rounder edges than those studied 10 years ago. Variations in the edge profile of hydrophobic IOLs were greater compared with the hydrophilic IOLs.

Toxic anterior segment syndrome: A review

Toxic anterior segment syndrome is a surgical complication characterized by a noninfectious anterior chamber inflammatory reaction having multiple etiologies. The clinical signs (prominent limbus-to-limbus corneal edema, anterior chamber inflammation) and symptoms (decreased visual acuity, discomfort) generally occur within the first 12-48 hours after intraocular surgery. Most patients achieve good clinical and visual outcomes when there is a prompt clinical diagnosis and adequate treatment. We review the literature on toxic anterior segment syndrome, emphasizing its etiology, pathophysiology, and clinical and surgical management, as well as prognosis and sequelae. Our goal is to reduce the frequency of toxic anterior segment syndrome by highlighting the importance of prevention, early recognition, and distinguishing toxic anterior segment syndrome from infectious endophthalmitis.

[Assessment of astigmatism associated with the iris-fixated ARTISAN aphakia implant: Anterior fixation versus posterior fixation, study of postoperative follow-up at one year]

PURPOSE

The goal of our retrospective, single-center study of a case series was to compare the total, corneal, and internal astigmatism, and the visual acuity at one year after combined or stand-alone surgery consisting of iris fixation of an iris-claw intraocular lens (ARTISAN aphakia) in aphakic patients, according to whether the lens was fixated to the anterior (n=21) or posterior (n=51) surface of the iris.

RESULTS

We did not find a significant difference between these two types of fixation for any of the studied variables. The surgically induced astigmatism was 1.67 D at 176° in group A versus 1.19 D at 11° in group P.

CONCLUSION

Although this surgery creates additional corneal astigmatism, it has not been proven that it differs depending on the type of fixation of the iris-claw. If we adhere to the notion that the posterior fixated iris-claw decreases the risk of endothelial decompensation in case the implant becomes disenclavated, then reverse iris fixation of the iris-claw makes sense.

Uveitis-Glaucoma-Hyphaema Syndrome. General review

Uveitis-Glaucoma-Hyphaema Syndrome (UGH syndrome, or "Ellingson" Syndrome) is a rare condition caused by the mechanical trauma of an intraocular lens malpositioned over adjacent structures (iris, ciliary body, iridocorneal angle), leading to a spectrum of iris transillumination defects, microhyphaemas and pigmentary dispersion, concomitant with elevated intraocular pressure (IOP). UGH Syndrome can also be characterized by chronic inflammation, secondary iris neovascularization, cystoid macular edema (CME). The fundamental step in the pathogenesis of UGH syndrome appears to arise from repetitive mechanical iris trauma by a malpositioned or subluxed IOL. These patients have uncomplicated cataract implants and return for episodes of blurry vision weeks to months after surgery. This may be accompanied by pain, photophobia, erythropsia, anterior uveitis, hyphaema along with raised intraocular pressure. A careful history and examination, as well as appropriate investigations can confirm the diagnostic. Treatment options are IOL Explantation exchange, topical and systemic medication, and cyclophotocoagulation, the placement of a Capsular Tension Ring to redistribute zonular tension and Anti-vascular endothelial growth factor (anti-VEGF) Therapy.

The Fate of Eyes with Anterior Chamber Intra-Ocular Lenses

A total of 143 anterior chamber (AC) intra-ocular lenses (IOL) of various designs were implanted in a five-year period and followed for 18 to 76 months. The lenses were inserted as a secondary implant after extracapsular cataract extraction (ECCE) complicated by vitrectomy, or after primary intra-capsular extraction. The complications (corneal edema, uveitis/glaucoma, extrusion/imbedding, cystoid macular edema), the final visual acuity and the need for removal of the IOL were analyzed. Only small differences were found between the different lenses but some association was found between complicated surgery (ECCE + vitrectomy) and a higher rate of complication, poorer visual outcome and more frequent need for IOL removal. Cystoid macular edema was encountered only in cases with complicated ECCE. A high percentage of other ocular pathologies was found among the cases, possibly implying that diseased eyes are more prone to surgical complications. An alternative to the AC-IOL in cases with a ruptured posterior capsule is the suture-supported posterior chamber IOL, but the flexible-loop AC-IOL may not yet be obsolete.

Decision-making and management of uveitic cataract

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.

Sutureless glueless intrascleral fixation of posterior chamber intraocular lens: Boon for aphakic

Purpose:

To report results of intrascleral fixation of 3-piece IOL without the help of suture and glue.

Methods:

Study included intrascleral fixation of haptic in 50 eyes by T-fixation technique. Preoperative and postoperative visual acuity, slit lamp and fundus examination, applanation tonometry, keratometry, biometry, optical coherence tomography, Scheimpflug imaging were done for extensive evaluation. Qualitative and quantitative data were summarized in the form of proportion and mean and standard deviation, respectively. The significance of difference was measured by Chi-square test or unpaired t-test or ANOVA whichever is appropriate. P < 0.05 was considered as statistically significant.

Results:

There was one case in which haptic broke during handshake maneuver and another IOL was required. Postoperative complications included corneal edema (4%), increased intraocular pressure (6%), cystoid macular edema (2%), decentration (4%), and dislocation (2%), which were all managed to the level of good visual recovery. There was no significant change in corneal astigmatism. There was significant change found in best-corrected visual acuity and uncorrected visual acuity after surgery.

Conclusion:

This modified technique seems to be a good alternative in IOL implantation in eyes with deficient capsules in view of the decrease in the learning time and surgical time and risk for complications.

Killing two birds with one stone: dual blockade of integrin and FGF signaling through targeting syndecan-4 in postoperative capsular opacification

The most common complication after cataract surgery is postoperative capsular opacification, which includes anterior capsular opacification (ACO) and posterior capsular opacification (PCO). Increased adhesion of lens epithelial cells (LECs) to the intraocular lens material surface promotes ACO formation, whereas proliferation and migration of LECs to the posterior capsule lead to the development of PCO. Cell adhesion is mainly mediated by the binding of integrin to extracellular matrix proteins, while cell proliferation and migration are regulated by fibroblast growth factor (FGF). Syndecan-4 (SDC-4) is a co-receptor for both integrin and FGF signaling pathways. Therefore, SDC-4 may be an ideal therapeutic target for the prevention and treatment of postoperative capsular opacification. However, how SDC-4 contributes to FGF-mediated proliferation, migration, and integrin-mediated adhesion of LECs is unclear. Here, we found that downregulation of SDC-4 inhibited FGF signaling through the blockade of ERK1/2 and PI3K/Akt/mTOR activation, thus suppressing cell proliferation and migration. In addition, downregulation of SDC-4 suppressed integrin-mediated cell adhesion through inhibiting focal adhesion kinase (FAK) phosphorylation. Moreover, SDC-4 knockout mice exhibited normal lens morphology, but had significantly reduced capsular opacification after injury. Finally, SDC-4 expression level was increased in the anterior capsule LECs of age-related cataract patients. Taken together, we for the first time characterized the key regulatory role of SDC-4 in FGF and integrin signaling in human LECs, and provided the basis for future pharmacological interventions of capsular opacification.

PREVENTING PUPILLARY CAPTURE AFTER VITRECTOMY AND TRANSSCLERAL FIXATION OF AN INTRAOCULAR LENS: Iridotomy Using a Vitrectomy Probe

PURPOSE

To investigate the effects of concurrent iridotomy using a vitreous cutter probe on the prevention of pupillary capture in patients undergoing transscleral fixation of intraocular lens implantation.

METHODS

A total of 79 eyes from 79 patients, who underwent transscleral fixation of intraocular lens without preexisting vitreoretinal disorders and who were followed up for 6 months were included. Subjects were divided into a noniridotomy group (51 eyes) and an iridotomy group (28 eyes). After conventional 23-gauge vitrectomy and transscleral fixation of intraocular lens implantation in all patients, 28 patients underwent concurrent iridotomy intraoperatively. The patients were followed up to evaluate the incidence of surgery-related complications, including pupillary capture.

RESULTS

There were no statistically significant differences in the preoperative demographic findings between the two groups (all P > 0.05). There was a significant difference in pupillary capture in 15 eyes (29.4%) of the noniridotomy group, compared with 1 eye (3.6%) of the iridotomy group (P = 0.007). There were no differences in postoperative best-corrected visual acuity between the two groups, and no iridotomy-related complications were observed.

CONCLUSION

Concurrent iridotomy using a vitreous cutter probe is an easy, rapid, and effective procedure to prevent possible pupillary capture after combined vitrectomy and transscleral fixation of intraocular lens implantation.

RP-HPLC detection and dosage method for acrylic monomers and degradation products released from implanted medical devices

Acrylic copolymers are useful in medical therapeutics. As in dental implants or intraocular lenses, acrylics are present in many medical devices or drug adjuvants. Industrial using of acrylics is still important in painting or textile manufacturing. Scientific research background has proved that acrylic suffer for depolymerized and cross-linking mechanisms under heating and photo-oxidative conditions. Those aging processes could lead to release of unreacted monomers and degradation products. We developed a new RP-HPLC method with good resolution, recovery, linearity, detection and quantification limits that is efficient for acrylic monomers quantification in in vitro and in vivo saline solution matrices. This method allows the detection of copolymer and medical devices degradation products too. Both the limit of quantification and the limit of detection for monomers and degradation products are above cytotoxic concentrations for human epithelial cells. Those biological results confirm the interest of the method for dosage of unreacted acrylics after polymerization and for the research of degradation products in body fluids as aqueous humor.

Complications and visual outcomes after secondary intraocular lens implantation in children

PURPOSE

To evaluate safety and visual outcomes in surgically aphakic children undergoing secondary intraocular lens (IOL) implantation.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

One hundred seventy-four eyes of 104 children (70 bilateral, 34 unilateral) who underwent secondary IOL implantation for aphakia after congenital cataract surgery at L. V. Prasad Eye Institute, Hyderabad, India, were analyzed. A minimum of 3 months of follow-up after surgery was required for inclusion in the study. Eyes with aphakia after surgery for traumatic cataracts and other associated ocular comorbidities were excluded. Main outcome measures were intraoperative and postoperative complications and visual outcome at the last follow-up.

RESULTS

Mean age at secondary IOL implantation was 6.08 ± 3.75 years. The mean follow-up was 25.7 ± 24.9 months. Mean best-corrected visual acuity improved from 1.08 ± 0.65 in aphakic children to 0.55 ± 0.51 logarithm of the minimal angle of resolution in pseudophakic children at last follow-up (P < .0001). Overall, 51 eyes (35%) attained a final best-corrected visual acuity of 20/40 (0.3 logarithm of the minimal angle of resolution) or better, whereas only 2 eyes (8.7%) attained a final best-corrected visual acuity of 20/40 (0.3 logarithm of the minimal angle of resolution) or better in children who underwent secondary IOL implantation for unilateral aphakia. The most common postoperative complications were secondary membrane formation (17 eyes; 9.77%), optic capture (15 eyes; 8.6%), IOL decentration (9 eyes; 5.17%), and secondary glaucoma (11 eyes; 5%).

CONCLUSIONS

Secondary sulcus IOL implantation in children is a relatively safe procedure and leads to favorable visual postoperative outcomes.

IOL tilt and decentration estimation from 3 dimensional reconstruction of OCT image

Purpose

To evaluate intraocular lens (IOL) tilt and decentration by anterior segment optical coherence tomography (AS-OCT) using 3-dimensional (3D) reconstruction method.

Design

Prospective observational case series.

Participants

Thirty-nine patients (39 eyes) were included.

Methods

The IOL positions of all eyes were examined by AS-OCT. Images were obtained in 4 axes (0–180 degrees, 45–225 degrees, 90–270 degrees, and 135–315 degrees) using the quadrant-scan model. The cross-sectional images were analyzed with MATLAB software.

Main Outcome Measures

The angle (θ) between the reference pupillary plane and the IOL plane, the distances between the center points of the pupil circle and the IOL on the x-axis (dx) and y-axis (dy) and the spatial distance (ds) were calculated after 3D-reconstruction.

Results

The mean angle (θ) between the pupillary plane and the IOL plane was 2.94±0.99 degrees. The mean IOL decentration of dx and dy was 0.32±0.26 mm and 0.40±0.27 mm, respectively. The ds of the IOL decentration was 0.56±0.31 mm. There was no significant correlation between the ocular residual astigmatism (ORA) and the tilted angle or the decentration distance. There was a significant correlation between the ORA and total astigmatism (r = 0.742, P<0.001). There was no significant correlation between the postoperative best corrected visual acuity (BCVA) and the ORA (r = 0.156; P = 0.344), total astigmatism (r = 0.012; P = 0.942), tilted angle (θ; r = 0.172; P = 0.295) or decentration distance (dx: r = 0.191, P = 0.244; dy: r = 0.253, P = 0.121; ds: r = 0.298, P = 0.065).

Conclusions

AS-OCT can be used as an alternative for the analysis of IOL tilt and decentration using 3D-reconstruction.

Sulcus implantation of a single-piece foldable acrylic intraocular lens after posterior capsular rupture in cataract surgery

PURPOSE

To evaluate the safety of a foldable acrylic single-piece intraocular lens (IOL) in cases of complicated cataract surgery and sulcus implantation. The setting was University and private anterior segment surgery practices.

METHODS

In this observational case series study, 13 eyes of 13 patients were included after complicated phacoemulsification with extensive posterior capsule rupture with or without vitreous loss. A foldable acrylic single-piece IOL (Rayner Superflex 620H; Rayner Intraocular Lenses Limited, Hove, East Sussex, UK) was implanted in the ciliary sulcus in each eye. Postoperative follow-up included best-corrected visual acuity, anterior segment biomicroscopy, IOL centration and position, intraocular pressure, and fundus biomicroscopy. Optical coherence tomography was performed in 2 subjects. Median follow-up time was 12 months (range 1-21 months).

RESULTS

Visual acuity 12 months after surgery was 6/18 and below in 5 eyes (39%), between 6/12 and 6/7.5 in 6 eyes (46%), and 6/6 in 2 eyes (15%). All patients experienced vision improvement. Postoperative complications included corneal edema (2 eyes), Descemet folds (1 eye), intraocular pressure elevations (3 eyes), and pronounced anterior segment inflammation (1 eye). Two eyes had minor pupil contour abnormalities. No significant IOL decentration was observed.

CONCLUSIONS

Sulcus implantation of a foldable acrylic single-piece IOL in eyes with complicated cataract surgery maintains the advantages of easy insertion and small incision. Postoperatively, all IOLs were centered, visual results were good, and complications were manageable and not IOL-related.

Modern cataract surgery: unfinished business and unanswered questions

We summarize information, based on clinicopathologic studies over the past decade, on various cataract intraocular lens (IOL) procedures and modern "specialized" IOLs, that will help surgeons continuously improve long-term results for cataract patients. Although most operations do initially provide excellent refractive correction and visual rehabilitation, late complications occur. These sometimes are missed because they are outside of the routine period of follow-up care. We have tried to determine if the various techniques and IOLs truly deliver the long-term results that we desire. Most safety and efficacy information is derived from the manufacturer and is passed through the U.S. Food and Drug Administration (FDA). This is often based on limited, relatively short-term observations made by the manufacturer. After a lens receives FDA approval, there are few means to assess the outcome of each procedure and lens years later. We rarely hear of a 10- or 20-year follow-up study. We have found that one of the best means to assess long-term results is pathologic analyses. We discuss recently studied aspects of pathologic reactions, such as posterior capsule opacification, intracapsular fibrosis, glistenings, intralenticular opacification, and other issues with the various IOL platforms; we then present a clinicopathological overview of tissues and IOLs from our database. These include hydrophobic and hydrophilic acrylic designs, plate lenses, and a dual optic lens.

Secondary IOL Implantation without Capsular Support: A Laser Flare Cell Meter Study

Phacoemulsification and the contemporary implantation of intraocular lens (IOL) within the capsular bag represent the standard of care in cataract surgery, but sometimes a primary IOL implant is not possible due to intraoperative complications or preexisting conditions so that a secondary implantation of IOL within the anterior or posterior chamber is necessary. The aim of our study was to assess the degree of inflammation due to a secondary implant of claw lenses, angle-supported IOLs, and scleral-fixated IOLs by means of an objective, repeatable, and noninvasive device, the laser flare cell meter, which evaluates aqueous flare and cells within the anterior chamber in vivo and to show the contribution of the single IOLs to the genesis of inflammation.

Polymethyl methacrylate intraocular lens opacification 20 years after cataract surgery: A case report in a tertiary eye hospital in Saudi Arabia

Snowflake degeneration is a slow progressive opacification of polymethyl methacrylate (PMMA) intraocular lenses (IOLs). This late postoperative complication can occur a decade or later after implantation. The deposits are composed of IOL materials that tend to aggregate centrally. There is a relative paucity of the literature on snowflake degeneration of IOLs. Symptoms can range from mild visual disturbance to significant loss of visual acuity. In cases of opacification after IOL implantation, the different diagnosis should include snowflake degeneration to prevent surgical intervention such as lens exchange or explantation unless clinically warranted. We report a case of late optical opacification of a PMMA IOL, the clinical diagnosis and treatment that increased best corrected vision.

Long-term pathologic follow-up of obsolete design: Choyce Mark VIII anterior chamber intraocular lens

We analyzed an enucleated eye that was blind and painful from a 66-year-old patient implanted with a Tennant modification of the Choyce Mark VIII anterior chamber intraocular lens (IOL) as a secondary procedure in 1978. The eye developed glaucoma, with implantation of an Ahmed valve in 2006. Gross and light microscopic analyses showed corneal decompensation and vascularization, peripheral anterior and posterior synechiae, iris thinning, significant changes in the iris pigmented layer, fibrous tissue on the anterior surface of the iris, and Soemmerring ring formation in the periphery of capsular bag remnants. In addition, there was severe attenuation of the nerve fiber layer and extensive cupping of the optic disc. The IOL surface was overall smooth and regular, without warping of the footplates, and was partially covered by clumps of various cell elements, including giant cells intermixed with pigment. This study represents the longest clinicopathologic correlation report on this IOL.

Evaluating exaggerated, prolonged, or delayed postoperative intraocular inflammation

PURPOSE

To provide a diagnostic approach for the evaluation of patients with exaggerated, prolonged, or delayed postoperative intraocular inflammation.

DESIGN

Perspective.

METHODS

Selected articles on normal and abnormal postoperative intraocular inflammation were reviewed and interpreted in the context of the authors' clinical and research experience.

RESULTS

In addition to infectious endophthalmitis, a number of noninfectious conditions characterized by exaggerated, prolonged, or delayed postoperative inflammation have been described. Heuristically, increased postsurgical inflammation may be categorized by time from surgery to first recognition using the following general guidelines: as immediate and occurring within 2 days after surgery; as early and occurring after 2 days, but within the first 2 weeks, after surgery; and as delayed and occurring more than 2 weeks after surgery.

CONCLUSIONS

Although infectious endophthalmitis always must be excluded as a cause of increased postoperative intraocular inflammation, potential noninfectious causes also exist. We review both infectious and noninfectious causes of increased postoperative inflammation and provide a diagnostic framework for evaluating such patients.