The Aravind Pseudoexfoliation Study: 5-Year Postoperative Results. The Effect of Intraocular Lens Choice and Capsular Tension Rings

Posterior capsule opacification treatment using Nd: YAG laser capsulotomy: 36 months retrospective analysis

BACKGROUND

The study aimed to identify factors influencing the time from cataract surgery to PCO treatment with Neodymium: Yttrium-Aluminium-Garnet (Nd: YAG) laser.

METHODS

For PCO risk factors analysis the retrospective study included 1045 eyes treated for PCO using Nd: YAG laser capsulotomy in the Hospital of Lithuanian University of Health Sciences (HLUHS) Kaunas Clinics with reduced best-corrected distance visual acuity (BCDVA) and opacity in the central 3 mm zone. Eyes with no comorbidities were categorized into groups according to the intraocular lense (IOL) implanted and the time from cataract operation to Nd: YAG capsulotomy was compared. Tests used for statistical analysis: Shapiro-Wilk, Kruskal-Wallis, Mann-Whitney, one-way independent ANOVA, Pearson's or Spearman's correlation coefficient, and multivariable linear regression.

RESULTS

A total of 918 patients (1045 eyes) were included. The median time from cataract surgery to capsulotomy was 39.0 (27.4-54.6) months (min. 2; max. 174), did not differ between men and women, and was shorter for junior surgeons (25.8 (19.8-35.1) months) compared to senior surgeons (39.6 (27.8-55.3) months) (p < 0.001). Seven factors affecting the time from cataract surgery to Nd: YAG capsulotomy were found: IOL model, surgeon's experience, BCDVA after surgery, capsular tension ring, pseudoexfoliation, BCDVA before capsulotomy and exudative age-related macular degeneration (adjusted R2 = 0.452; p < 0.001). The IOL model was the only factor with a strong correlation. The median time from cataract surgery to capsulotomy differed between all IOL groups: Acriva UD613 group 31.5 (23.0-38.0) months, Johnson&Johnson Tecnis ZCB00 group 41.0 (33.5-66.5) months, Bausch&Lomb Envista MX60 group 45.0 (38.5-54.5) months, and Alcon Acrysof IQ SN60WF group 53.0 (41.5-79.5) months.

CONCLUSIONS

The IOL model seems to have the greatest influence on the time from cataract surgery to Nd: YAG capsulotomy. Acrylic hydrophobic IOLs with a square optical edge have different times from cataract surgery to Nd: YAG capsulotomy. Hydrophobic acrylic IOL seems to have a longer time from cataract surgery to Nd: YAG capsulotomy compared to hydrophilic acrylic IOL with a hydrophobic surface.

Clinical and laboratory studies on the effects of capsular tension ring on surgical outcomes of trifocal intraocular lens implantation

PURPOSE

To assess the influence of capsular tension ring (CTR) on surgical outcomes of trifocal intraocular lens (IOL) implantation in femtosecond laser-assisted cataract surgery.

SETTING

Sugita Eye Clinic, Tokyo, and University of Tsukuba, Ibaraki, Japan.

DESIGN

Prospective, randomized, paired-eye clinical study and laboratory study.

METHODS

In the clinical study involving 44 eyes of 22 patients with no risk of zonular instability, 1 eye received IOL alone and the contralateral eye received IOL with CTR. Preoperative capsular bag diameter and postoperative IOL tilt/decentration were measured using anterior segment optical coherence tomography. In the laboratory study, IOL and CTR were implanted into an artificial capsular bag of 10 mm in diameter, and IOL centration was evaluated.

RESULTS

Throughout the 12-month follow-up period, there was no significant difference in refractive and visual outcomes between groups. The amount of IOL decentration was significantly larger in eyes with CTR than in eyes without CTR at 12 months postoperatively (P = .037). There was a significant negative correlation between capsular bag diameter and the amount of IOL decentration in eyes with CTR (P = .038), but not in eyes without CTR (P = .873). The laboratory study indicated that interference between CTR eyelets and IOL haptics significantly increased IOL decentration (P < .001).

CONCLUSIONS

The use of CTR did not affect refractive and visual outcomes of trifocal IOL implantation in eyes without the risk of zonular weakness. CTR coimplantation increased IOL decentration possibly due to the interference between CTR eyelets and IOL haptics.

Three-piece intraocular lens in the sulcus with optic capture in patients with mild to moderate zonular weakness in exfoliation

Purpose

To study the use of sulcus placement of a 3-piece intraocular lens (IOL) with optic capture in patients with exfoliation with zonular weakness.

Methods

Data on all exfoliation patients who had direct or indirect evidence of zonular weakness and had a 3-piece IOL implanted in the sulcus with optic capture over a 5-year period between January 2017 and January 2022 were included in this retrospective case series.

Results

The study comprised of 35 eyes of 35 patients. The mean age at surgery of the 20 male and 13 female patients was 75.21 years ± 5.74 (standard deviation (SD)). The mean pupillary diameter was 5.77 ± 2.23 mm (range: 10 to 3 mm). A capsular tension ring (CTR) was used in 17 cases and iris hooks as a pupil-expanding device were used in 15 cases. No patients had an increase in inflammation after surgery and there were no late subluxation or dislocation of "in the bag" posterior chamber IOL or major complications. There was a significant improvement in visual acuity.

Conclusion

The sulcus placement of 3-piece IOL with optic capture is the ideal technique in patients with clinical or intraoperative evidence of mild to moderate zonular weakness. It may also be more appropriate in relatively younger patients (in the fifties or sixties) with exfoliation with no overt zonulopathy to prevent late subluxation or dislocation of "in the bag" IOL.

Lens Epithelial Cell Removal in Routine Phacoemulsification: Is It Worth the Bother?

PURPOSE

To review the literature on crystalline lens epithelial cell (LEC) removal in routine phacoemulsification and determine whether it should be incorporated as part of a surgeon's standard technique.

DESIGN

Perspective.

METHODS

Expert commentary with video demonstrations on techniques of removal of LECs and associated potential complications. Discussion incorporates the importance of LEC removal, a review of techniques to prevent posterior capsular opacification (PCO), and the effects of intraocular lens design on LEC proliferation and PCO.

RESULTS

The evidence suggests that LEC removal should be routinely performed as it can be carried out safely and with considerable short- and long-term benefits for patients. With effective cleanup, there is reduced anterior capsule opacification, fibrosis, and decentration of the capsular bag as well as reduced rates of posterior capsular opacification. Techniques for removal are easy to learn, with very low complication rates, and can reduce the risk of the long-term need for technically complex procedures such as intraocular lens explantation.

CONCLUSIONS

LEC removal from both the anterior and posterior capsule is part of a continuous, incremental improvement of cataract surgery and should be introduced to ophthalmology trainees during their formative years as part of their regular cataract surgery armamentarium.

Manual small incision cataract surgery: a viable option for cataract with pseudoexfoliation

PURPOSE

The aim of the study was to assess the spectrum of clinical presentation, intraoperative challenges and immediate surgical outcome of cataract patients with pseudoexfoliation syndrome (PXF) following manual small incision cataract surgery (MSICS).

METHODS

This prospective observational study which was conducted in a rural tertiary care hospital included adult patients with cataract and associated PXF. MSICS was performed for all after a complete ophthalmic and systemic examination. Clinical profile, intraoperative and post-operative complications were noted. Uncorrected visual acuity on first day post-surgery was used to assess the surgical outcome following MSICS.

RESULTS

MSICS was performed in 80 eyes with varying grades of cataract and PXF. The mean age of the patients was 62.5 ± 8.9 years. PXF material on pupillary margin in 77(96%) patients was the most common finding noted. Majority of the patients had advanced cataract (72, 90%) and inadequate mydriasis (62, 77.5%). Posterior capsular rent (8, 10%) and zonular dehiscence (8, 10%) were the intraoperative difficulties faced. Uncorrected visual outcome on first post-operative day was moderate to good in 71 (88.8%) patients, limited by post-operative corneal oedema (21, 26.3%), iritis (31, 38.8%) and aphakia (9, 11.3%).

CONCLUSION

Patients with pseudoexfoliation had poor pupillary dilatation, advanced cataracts and higher rate of posterior capsular rent. Our study showed good outcome of MSICS in PXF patients, even with advanced cataract suggesting that MSICS is a safe, effective and viable option for patients with PXF and cataract.

The effect of capsule tension ring on posterior capsule opacification: A meta-analysis

Background

Posterior capsule opacification is one of the most common complications after cataract surgery. Studies have suggested that the introduction of a capsule tension ring might play a critical role in the prevention of capsule opacification, yet quantitative evidence is still lacking. This work consists of a meta-analysis on available data in order to explore the influence of a capsule tension ring on posterior capsule opacification.

Methods

A comprehensive review of the literature on capsule tension ring and posterior capsule opacification was carried out using the Embase, Pubmed, Web of Science, and Cochrane electronic databases. The selected studies included randomized controlled trials, retrospective studies and prospective studies published before June 2020. The studies of interest were selected by two reviewers independently from the included studies. Odds ratios (ORs) and standardized mean differences (SMD) were used in order to assess the association. A fixed-effects model or a random-effects model was applied to combine data according to heterogeneities. Sensitivity analysis was used to assess the heterogeneity of the studies. Publication bias was estimated using the Egger test. Statistical analysis was performed using the stata15.1 software.

Results

The meta-analysis included in total 8 studies involving 379 cases and 333 controls. There was a statistically significant difference of Nd:YAG laser capsulotomy rate (OR=0.241, 95% CI: 0.145, 0.400 I²=42.1%) between the capsule tension ring group and the control group, indicating that the tension ring reduced the Nd:YAG laser capsulotomy rate. Further studies with continuous data also revealed that the use of capsule tension ring was associated with a lower posterior capsule opacification score (SMD = -1.402, 95% CI: -2.448, -0.355 I²=95.0%). The sensitivity analysis suggested that the result of the re-combined analysis did not change notably, indicating that the result was reliable and stable. Both pooled analysis showed no evidence of publication bias.

Conclusion

The findings of this meta-analysis confirmed that capsule tension ring might reduce capsule opacification. Further studies should be made to validate the result.